ORCID Profile
0000-0002-0918-7540
Current Organisation
University of Sydney
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Publisher: Wiley
Date: 29-04-2019
DOI: 10.1111/NEP.13530
Abstract: To compare quality of life (QOL) of caregivers of dialysis patients with the cared for patients and population norms. The ACTIVE Dialysis study randomized participants to extended (median 24 h/week) or standard (median 12 h/week) haemodialysis hours for 12 months. A subgroup of participants and their nominated caregivers completed QOL questionnaires including the EuroQOL-5 Dimension-3 Level (EQ5D-3 L), short form-36 (SF-36, also allowing estimation of the SF-6D), as well as a bespoke questionnaire and the personal wellbeing index (PWI). Caregiver QOL was compared with dialysis patient QOL and predictors of caregiver QOL were determined using multivariable regression. There were 54 patients and caregiver pairs, predominantly from China. Caregivers mean (SD) age was 53.4 (11.3) years, 60% were female, 71% cared for their spouse artner, and 36% were educated to university level. Caregivers had better physical but similar mental QOL compared with dialysis patients (mean SF-36 physical component summary: 46.9 ± 8.7 vs 40.4 ± 10.2, P < 0.001 mental component summary: 47.8 ± 9.7 vs 49.6 ± 12.0, P = 0.84). Health utility measured with EQ5D-3 L was not significantly different between caregivers and dialysis patients (mean 0.869 ± 0.185 vs 0.798 ± 0.227, P = 0.083). Caregiver PWI was 43.7 ± 15.5, significantly lower than the Chinese population norm (68.2 ± 14.2, P < 0.001). Higher physical and mental QOL among caregivers was predicted by university education but not age, gender or daily hours caring. Caregivers have higher physical and equivalent mental QOL to dialysis patients but poorer personal well-being than the Chinese population. University education predicts better QOL and may be a surrogate for socioeconomic or other factors. (NCT00649298).
Publisher: Springer Science and Business Media LLC
Date: 28-07-2022
DOI: 10.1186/S43058-022-00326-X
Abstract: Clinical decision support (CDS) is increasingly used to facilitate chronic disease care. Despite increased availability of electronic health records and the ongoing development of new CDS technologies, uptake of CDS into routine clinical settings is inconsistent. This qualitative systematic review seeks to synthesise healthcare provider experiences of CDS—exploring the barriers and enablers to implementing, using, evaluating, and sustaining chronic disease CDS systems. A search was conducted in Medline, CINAHL, APA PsychInfo, EconLit, and Web of Science from 2011 to 2021. Primary research studies incorporating qualitative findings were included if they targeted healthcare providers and studied a relevant chronic disease CDS intervention. Relevant CDS interventions were electronic health record-based and addressed one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolaemia. Qualitative findings were synthesised using a meta-aggregative approach. Thirty-three primary research articles were included in this qualitative systematic review. Meta-aggregation of qualitative data revealed 177 findings and 29 categories, which were aggregated into 8 synthesised findings. The synthesised findings related to clinical context, user, external context, and technical factors affecting CDS uptake. Key barriers to uptake included CDS systems that were simplistic, had limited clinical applicability in multimorbidity, and integrated poorly into existing workflows. Enablers to successful CDS interventions included perceived usefulness in providing relevant clinical knowledge and structured chronic disease care user confidence gained through training and post training follow-up external contexts comprised of strong clinical ch ions, allocated personnel, and technical support and CDS technical features that are both highly functional, and attractive. This systematic review explored healthcare provider experiences, focussing on barriers and enablers to CDS use for chronic diseases. The results provide an evidence-base for designing, implementing, and sustaining future CDS systems. Based on the findings from this review, we highlight actionable steps for practice and future research. PROSPERO CRD42020203716
Publisher: Elsevier BV
Date: 08-2004
DOI: 10.1111/J.1467-842X.2004.TB00441.X
Abstract: To estimate the number and proportion of children in New South Wales affected by parental incarceration, and to describe the health impact of punitive incarceration on the children of prisoners. In 2001, NSW Corrections Health Service conducted a cross-sectional survey of prison inmates randomly selected from each of the 29 prisons in NSW, representing 11% of male and 30% of female inmates in the State. The survey included questions regarding parental status and number of children. A population model was developed, which incorporated increases in the prison population and reci ism, to estimate the number of children under 16 years of age in NSW ever having experienced parental incarceration. In 2001, there were approximately 14,500 children under the age of 16 years in NSW who experienced parental incarceration during the year. It is estimated that in 2001 there were 60,000 children under 16 years in NSW who had ever experienced parental incarceration in their lifetime, representing 4.3% of all children and 20.1% of Indigenous children. The number of children who have experienced parental incarceration is significant in NSW and across Australia. Indigenous children are much more likely to experience parental incarceration than non-Indigenous children. Children of prisoners are at high risk of negative health outcomes and are themselves at an increased risk of offending later in life. The needs of these children must be recognised and policies introduced to reduce the adversities they face. The social, politico-legal and economic conditions that are contributing to the continuing rise in incarceration rates must be recognised, and measures must be taken to reduce this trend.
Publisher: Springer Science and Business Media LLC
Date: 17-06-2021
DOI: 10.1186/S12913-021-06612-Z
Abstract: Rates of end-stage kidney disease in Australia are highest in the Northern Territory (NT), with the burden of disease heaviest in remote areas. However, the high cost of delivering dialysis services in remote areas has resulted in centralisation, requiring many people to relocate for treatment. Patients argue that treatment closer to home improves health outcomes and reduces downstream healthcare use. Existing dialysis cost studies have not compared total health care costs associated with treatment in different locations. To estimate and compare, from a payer perspective, the observed health service costs (all cause hospital admissions, emergency department presentations and maintenance dialysis) associated with different dialysis models in urban, rural and remote locations. Using cost weights attributed to diagnostic codes in the NT Department of Health’s hospital admission data set (2008–2014), we calculated the mean (SD) total annual health service costs by dialysis model for 995 dialysis patients. Generalized linear modeling with bootstrapping tested the marginal cost differences between different explanatory variables to estimate ‘best casemix’/‘worst casemix’ cost scenarios. The mean annual patient hospital expenditure was highest for urban models at $97 928 (SD $21 261) and $43 440 (SD $5 048) and lowest for remote at $19 584 (SD $4 394). When combined with the observed maintenance dialysis costs, expenditure was the highest for urban models at $148 510 (SD $19 774). The incremental cost increase of dialysing in an urban area, compared with a rural area, for a relocated person from a remote area, was $5 648 more and increased further for those from remote and very remote areas to $10 785 and $15 118 respectively. This study demonstrates that dialysis treatment in urban areas for relocated people has health and cost implications that maybe greater than the cost of remote service delivery. The study emphasises the importance of considering all health service costs and cost consequences of service delivery models. Relocation for dialysis treatment has serious health and economic consequences. Relocated people have low dialysis attendance and high hospital costs in urban areas. While remote dialysis service models are more expensive than urban models, the comparative cost differences are significantly reduced when all health service costs are included. The delivery of equitable and accessible dialysis service models requires a holistic approach that incorporates the needs of the patient hence dialysis cost studies must consider the full range of cost impacts beyond the dialysis treatments alone.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-10-2019
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2017
Publisher: Elsevier BV
Date: 07-2019
DOI: 10.1016/J.SOCSCIMED.2019.06.004
Abstract: There are significant health and social disparities between the world's Indigenous and non-Indigenous people on factors likely to influence quality of life (QOL) and wellbeing. However, these disparities in wellbeing are not captured in conventional QOL instruments, as they often do not include dimensions that are likely to be relevant to Indigenous people. The objective of this comprehensive literature review was to identify these wellbeing domains for Aboriginal and Torres Strait Islander people in Australia (hereafter, respectfully referred to collectively as Indigenous Australians). We searched PsycINFO, MEDLINE, Econlit, CINAHL, and Embase (from inception to June 2017, and updated in March 2019), and grey literature sources using keywords relating to adult Indigenous Australians' QOL and wellbeing. From 278 full-text articles assessed for eligibility, 95 were included in a thematic analysis. This synthesis revealed nine broad interconnected wellbeing dimensions: autonomy, empowerment and recognition family and community culture, spirituality and identity Country basic needs work, roles and responsibilities education physical health and mental health. The findings suggest domains of wellbeing relevant to and valued by Indigenous Australians that may not be included in existing QOL and wellbeing instruments, domains that may be shared with Indigenous populations globally. This indicates the need for a tailored wellbeing instrument that includes factors relevant to Indigenous Australians. Developing such an instrument will ensure meaningful, culturally-relevant measurement of Indigenous Australians' wellbeing.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 15-04-2014
Publisher: Springer Science and Business Media LLC
Date: 30-09-2022
DOI: 10.1186/S13063-022-06783-Y
Abstract: This update summarises key changes made to the protocol since the publication of the original protocol for the NAVKIDS 2 trial of patient navigators for children with chronic kidney disease (CKD) experiencing social disadvantage and provides the statistical analysis plan (SAP) which has not previously been published. The original protocol was published in BMC Nephrology ( 0.1186/s12882-019-1325-y ) prior to the commencement of trial recruitment. During the course of the trial, some key methodological changes needed to be made including changes to eligibility criteria (addition of patients with CKD stages 1–2, broadening of financial status eligibility criterion, addition of patients living in rural/remote areas, modification of age eligibility to 0–16 years, addition of limits related to the language spoken by family, guidance regarding families with multiple eligible children), changes to sites, reduction of s le size, addition of virtual options for consent and study procedures in response to the COVID-19 pandemic, removal of staggered recruitment across sites, addition of outcomes, and changes to the timing and number of assessments. This update summarises the changes made and their rationale and provides the detailed plan for statistical analysis of the trial. These changes have been finalised prior to the completion of study follow-up and the commencement of data analysis. Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618001152213 . Prospectively registered on 12 July 2018
Publisher: Wiley
Date: 19-09-2012
DOI: 10.1111/CTR.12004
Abstract: Ongoing debate about how to maximize the benefit of scarce organs while maintaining equity of access to transplantation exists. This study aims to synthesize healthcare provider perspectives on wait-listing and organ allocation. MEDLINE, Embase, and PsycINFO were searched till February 21, 2011. Quantitative data were extracted, and a qualitative synthesis of the studies was conducted. Twenty studies involving 4254 respondents were included. We identified two goals underpinning healthcare provider preferences for organ allocation: (i) maximize clinical benefit (quality of life gains, patient survival, treatment adherence, and graft survival) and social outcomes (social support, productivity, and valuation) (ii) achieve equity (waiting time, patient preferences, access to live donation, and medical urgency). Maximizing clinical or social outcomes meant organs would be preferentially given to patients expected to achieve good transplant outcomes or wider social gain. Achieving equity meant all patients should have an equal chance of transplant, or patients deemed more urgent receive higher priority. A tension between equity and efficiency is apparent. Balanced against dimensions of efficiency were considerations to instill a degree of perceived fairness in organ allocation. Ongoing engagement with stakeholders is needed to enhance transparency, a reasonable balance between efficiency and equity, and avoid discrimination against specific populations.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2017
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 21-10-2020
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 15-04-2010
Publisher: Springer Science and Business Media LLC
Date: 30-09-2009
DOI: 10.1245/S10434-008-0164-Z
Abstract: The aim of this study was to determine the cost-effectiveness of wide excision (WEX) + sentinel node biopsy (SNB) compared with WEX only in patients with primary melanomas >/=1 mm in thickness. A Markov model was populated with probabilities of disease progression and survival from the published literature. Costs were obtained from diagnostic-related group weightings and health outcomes were measured in quality-adjusted life years (QALYs). Base case analyses suggested that, over a 20-year timeframe, the mean total cost per patient receiving WEX only was AU $23,182 with 10.45 life years (LY) and 9.90 QALYs. The mean cost per patient for WEX + SNB was AU $24,045 with 10.77 LY and 10.34 QALYs. The incremental cost effectiveness ratio for WEX + SNB was AU $2,770 per LY and AU $1,983 per QALY. WEX + SNB appears to offer an improvement in health outcomes (in both LYs and QALYs) with only a slight increase in cost.
Publisher: Wiley
Date: 2011
Publisher: Springer Science and Business Media LLC
Date: 17-08-2021
DOI: 10.1186/S12874-021-01366-Y
Abstract: While web conferencing technologies are being widely used in communication and collaboration, their uptake in conducting research field work has been relatively slow. The benefits that these technologies offer researchers for engaging with hard-to-reach populations are beginning to be recognised, however, the acceptability and feasibility of using web conferencing technology to engage Aboriginal and Torres Strait Islander young people in research is unknown. This study aims to evaluate whether the use of web conferencing to engage Aboriginal and Torres Strait Islander young people in research is an acceptable and feasible alternative to conventional face-to-face methods. Aboriginal and Torres Strait Islander young people aged between 18 and 24 years were recruited via emails, flyers and snowballing to participate in an Online Yarning Circle (OYC) about wellbeing conducted via web conferencing. Five young Aboriginal and Torres Strait Islander Australians were trained as peer facilitators and each conducted one or more OYCs with support from an experienced Aboriginal and Torres Strait Islander researcher. The OYCs were recorded and the researchers conducted post-OYC interviews with the facilitators. OYC recordings, facilitator interviews and researchers’ reflections about the method were analysed to assess acceptability and feasibility for use with this population. 11 OYCs were conducted with 21 participants. The evaluation focused on (a) acceptability of the method for participants and facilitators and (b) feasibility of data collection method and procedures for use in research. Our evaluation revealed good acceptability and feasibility of the method, with only minor challenges experienced, which were predominantly logistical in nature and related to scheduling, obtaining documentation of consent, and technical issues. These challenges were offset by the greater control over the level of engagement that was comfortable for in idual participants and the greater ease with which they felt they could withdraw from participating. This shift in the traditional researcher-participant power dynamic was recognised by both participants and peer facilitators and was regarded as a support for Aboriginal and Torres Strait Islander young people’s participation in research. The use of web conferencing to engage Aboriginal and Torres Strait Islander young people in research offers an acceptable and feasible alternative to face-to-face research methods. The benefits conferred by these technologies associated with yielding greater control and power to the research participant has broad relevance to research with marginalised populations.
Publisher: Springer Science and Business Media LLC
Date: 24-03-2202
DOI: 10.1007/S40271-021-00507-1
Abstract: Adjuvant immunotherapy is a new treatment paradigm for adults with resected stage 3 melanoma. However, therapy can lead to long-term adverse health impacts, making immunotherapy decisions difficult. This study aimed to explore patients and their partners' views when considering whether to commence adjuvant immunotherapy. Focus groups and in-depth interviews were conducted among adults with resected stage 3 melanoma and their partners between August 2019 and April 2020. Factors important to adjuvant immunotherapy decision making were explored. Recruitment continued until data saturation, with thematic analysis performed. Thirty-six participants were recruited across two cohorts, including 24 patients (mean age 65 years, 71% male), and 12 partners (mean age 69 years, 75% female). Twenty-two patients (92%) received adjuvant immunotherapy, two (8%) declined. Five patients (21%) ceased treatment early because of toxicity. Five themes about adjuvant immunotherapy were common to all participants: (1) life and death (2) perceived risks and benefits (3) seeking information (4) healthcare team relationship and (5) immunotherapy treatment considerations. Prolonging life was the primary consideration, with secondary concerns about treatment burden, timing, costs and efficacy. This information can be used by clinicians to support melanoma treatment decision making.
Publisher: SAGE Publications
Date: 17-01-2020
Abstract: Fear of catastrophic events and uncertainty about safety at home are barriers to choosing peritoneal dialysis (PD). Remote monitoring may address these concerns and is increasingly being used in patients on automated peritoneal dialysis (APD). This study aims to describe clinicians’ perspectives and experiences of remote monitoring in caring for patients on PD. We conducted semi-structured interviews with nephrologists and dialysis nurses across nine dialysis units in New Zealand who had experience using remote monitoring with patients on APD. Interviews were transcribed and analysed using thematic analysis. Thirteen registered nurses and 12 nephrologists or nephrologists-in-training (total N = 25) participated. Four themes were identified: promoting and maintaining PD (providing reassurance to patients through continual surveillance, supporting confidence at home and sustaining PD as the patient-preferred treatment) enabling data-driven decisions (using comprehensive clinical data in providing timely and accessible care, and identifying and supporting patient adherence) establishing boundaries for use (negotiating privacy and independence, clarifying clinician and patient responsibilities and strengthening nursing innovation and capability) and enhancing patient-focused care (developing empathy for patients, enabling self-management and reducing time and financial burden in accessing care). Remote monitoring is valued by clinicians in promoting and maintaining patients on PD and enabling data-driven decisions. Remote monitoring enhances patient-focused care, but clinicians also emphasise the need to protect patient privacy and establish boundaries for use. Remote monitoring that supports the clinicians’ role and adheres to principles of data security maintains patient privacy may enhance care and outcomes for patients on PD.
Publisher: American Medical Association (AMA)
Date: 10-2018
Publisher: Springer Science and Business Media LLC
Date: 26-11-2010
Abstract: The National Cervical Screening Program in Australia currently recommends that sexually active women between the ages of 18-70 years attend routine screening every 2 years. The publically funded National HPV Vaccination Program commenced in 2007, with catch-up in females aged 12-26 years conducted until 2009 and this may prompt consideration of whether the screening interval and other aspects of the organized screening program could be reviewed. The aim of the current evaluation was to assess the epidemiologic outcomes and cost implications of changing the recommended screening interval in Australia to 3 years. We used a modelling approach to evaluate the effects of moving to a 3-yearly recommended screening interval. We used data from the Victorian Cervical Cytology Registry over the period 1997-2007 to model compliance with routine screening under current practice, and registry data from other countries with 3-yearly recommendations to inform assumptions about future screening behaviour under two alternative systems for screening organisation - retention of a reminder-based system (as in New Zealand), or a move to a call-and-recall system (as in England). A 3-yearly recommendation is predicted to be of similar effectiveness to the current 2-yearly recommendation, resulting in no substantial change to the total number of incident cervical cancer cases or cancer deaths, or to the estimated 0.68% average cumulative lifetime risk of cervical cancer in unvaccinated Australian women. However, a 3-yearly screening policy would be associated with decreases in the annual number of colposcopy and biopsy procedures performed (by 4-10%) and decreases in the number of treatments for pre-invasive lesions (by 2-4%). The magnitude of the decrease in the number of diagnostic procedures and treatments would depend on the method of screening organization, with call-and-recall screening associated with the highest reductions. The cost savings are predicted to be of the order of A$10-18 M annually, equivalent to 6-11% of the total cost of the current program (excluding overheads), with call-and-recall being associated with the greatest savings. Lengthening the recommended screening interval to 3 years in Australia is not predicted to result in increases in rates of cervical cancer and is predicted to decrease the number of women undergoing diagnostic and treatment procedures. These findings are consistent with a large body of international evidence showing that screening more frequently than every three years with cervical cytology does not result in substantial gains in screening effectiveness.
Publisher: Springer Science and Business Media LLC
Date: 26-08-2022
DOI: 10.1186/S12966-022-01340-X
Abstract: Physical activity mass media c aigns can deliver physical activity messages to many people, but it remains unclear whether they offer good value for money. We aimed to investigate the cost-effectiveness, cost-utility, and costs of physical activity mass media c aigns. A search for economic evaluations (trial- or model-based) and costing studies of physical activity mass media c aigns was performed in six electronic databases (June/2021). The authors reviewed studies independently. A GRADE style rating was used to assess the overall certainty of each modelled economic evaluation. Results were summarised via narrative synthesis. Twenty-five studies (five model-based economic evaluations and 20 costing studies) were included, and all were conducted in high-income countries except for one costing study that was conducted in a middle-income country. The methods and assumptions used in the model-based analyses were highly heterogeneous and the results varied, ranging from the intervention being more effective and less costly (dominant) in two models to an incremental cost of US$130,740 (2020 base year) per QALY gained. The level of certainty of the models ranged from very low ( n = 2) to low ( n = 3). Overall, intervention costs were poorly reported. There are few economic evaluations of physical activity mass media c aigns available. The level of certainty of the models was judged to be very low to low, indicating that we have very little to little confidence that the results are reliable for decision making. Therefore, it remains unclear to what extent physical activity mass media c aigns offer good value for money. Future economic evaluations should consider selecting appropriate and comprehensive measures of c aign effectiveness, clearly report the assumptions of the models and fully explore the impact of assumptions in the results. bit.ly/3tKSBZ3
Publisher: BMJ
Date: 07-2021
DOI: 10.1136/BMJOPEN-2020-048395
Abstract: One in three people aged 65 years and over fall each year. The health, economic and personal impact of falls will grow substantially in the coming years due to population ageing. Developing and implementing cost-effective strategies to prevent falls and mobility problems among older people is therefore an urgent public health challenge. StandingTall is a low-cost, unsupervised, home-based balance exercise programme delivered through a computer or tablet. StandingTall has a simple user-interface that incorporates physical and behavioural elements designed to promote compliance. A large randomised controlled trial in 503 community-dwelling older people has shown that StandingTall is safe, has high adherence rates and is effective in improving balance and reducing falls. The current project targets a major need for older people and will address the final steps needed to scale this innovative technology for widespread use by older people across Australia and internationally. This project will endeavour to recruit 300 participants across three sites in Australia and 100 participants in the UK. The aim of the study is to evaluate the implementation of StandingTall into the community and health service settings in Australia and the UK. The nested process evaluation will use both quantitative and qualitative methods to explore uptake and acceptability of the StandingTall programme and associated resources. The primary outcome is participant adherence to the StandingTall programme over 6 months. Ethical approval has been obtained from the South East Sydney Local Health District Human Research Ethics Committee (HREC reference 18/288) in Australia and the North West- Greater Manchester South Research Ethics Committee (IRAS ID: 268954) in the UK. Dissemination will be via publications, conferences, newsletter articles, social media, talks to clinicians and consumers and meetings with health departments/managers. ACTRN12619001329156.
Publisher: Elsevier BV
Date: 10-2010
DOI: 10.1016/J.PEC.2010.01.001
Abstract: To evaluate the effect of a decision aid (DA) on women's knowledge of the benefits and harms of screening and on their ability to make an informed decision. An online randomized controlled trial among 321 women aged 38-45 years was conducted. Participants were randomized to either immediate or delayed access to the online DA which (i) explained the benefits and harms, (ii) included a values clarification exercise and a worksheet to support decision making. The primary outcome, knowledge of benefits and harms of screening, and secondary outcomes, informed choice (composite of knowledge, values and intention), anxiety and acceptability of the DA were measured using online questionnaires. Women in the intervention group were more knowledgeable (mean score out of 10, 7.35 vs 6.27, p<0.001) and were more likely to have made a decision (82% vs 61% p<0.001). Of those who made a decision, women in the intervention group were less likely to start screening now (52% vs 65% p=0.05). There was no significant difference in the proportion of women who made an informed choice (71% intervention group vs 64% control group, p=0.24). The DA was helpful, balanced and clear, and did not make women anxious. The DA increased knowledge and reduced indecision, without increasing feelings of anxiety. This decision aid is easy to access online and could be an inexpensive way of supporting women aged 40 who are considering whether to start screening now, or wait until they are 50. The results of this study demonstrate the potential of DAs to help inform women about both the benefits and risks of screening at this age and to support women and clinicians in this decision making process.
Publisher: Oxford University Press (OUP)
Date: 21-12-2011
DOI: 10.1093/NDT/GFR683
Abstract: Transplantation is the treatment of choice for organ failure, but a worldwide shortage of suitable organs exists. We conducted a systematic review of qualitative studies that explored community attitudes towards living and deceased solid organ donation to inform strategies to improve organ donation rates. Medline, Embase, PsycINFO and EconLIT were searched. Qualitative studies that explored community attitudes towards living and deceased solid organ donation were included. A thematic synthesis of the results and conclusions reported by primary authors was performed. Eighteen studies involving 1019 participants were identified. Eight themes emerged. The decision to be an organ donor was influenced by (i) relational ties (ii) religious beliefs (iii) cultural influences (iv) family influences (v) body integrity (vi) previous interactions with the health care system-medical mistrust, validity of brain death and fear of early organ retrieval (vii) the in idual's knowledge about the organ donation process and (viii) major reservations about the process of donation, even in those who support organ donation. This review of qualitative studies highlights that seemingly intractable factors, such as religion and culture, are often tied in with more complex issues such as a distrust of the medical system, misunderstandings about religious stances and ignorance about the donation process. Intervention that could be considered includes culturally appropriate strategies to engage minority groups, especially through religious or cultural leaders, and more comprehensively available information about the donation process and its positive outcomes.
Publisher: Elsevier BV
Date: 03-2010
DOI: 10.1111/J.1524-4733.2009.00668.X
Abstract: Chronic kidney disease is, increasingly, both a contributor to premature deaths and a financial burden to the health system, and is estimated to affect between 10% and 15% of the adult population in Western countries. Hypertension and, in particular diabetes, are significant contributors to the global burden of chronic kidney disease. Although it might increase costs, screening for, and improved management of, persons at increased risk of progressive kidney disease could improve health outcomes. We therefore sought to estimate the costs and health outcomes of alternative strategies to prevent end-stage kidney disease, compared with usual care. A Markov model comparing: 1) intensive management versus usual care for patients with suboptimally managed diabetes and hypertension and 2) screening for and intensive treatment of diabetes, hypertension, and proteinuria versus usual care was developed. Intervention effectiveness was based on published meta-analyses and randomized controlled trial data costs were measured from a central health-care funder perspective in 2008 Australian dollars ($A), and outcomes were reported in quality-adjusted life-years (QALYs). Intensive treatment of inadequately controlled diabetes was both less costly (an average lifetime saving of $A133) and more effective (with an additional 0.075 QALYs per patients) than conventional management. Intensive management of hypertension had an incremental cost-effectiveness ratio (ICER) $A2588 per QALY gained. Treating all known diabetics with angiotensin-converting enzyme (ACE) inhibitors was both less costly (an average lifetime saving of $A825 per patient) and more effective than current treatment (resulting in 0.124 additional QALYs per patient). Primary care screening for 50- to 69-year-olds plus intensive treatment of diabetes had an ICER of $A13,781 per QALY gained. Primary care screening for hypertension (between ages 50 and 69 years) plus intensive blood pressure management had an ICER of $A491 per QALY gained. Primary care screening for proteinuria (between ages 50 and 69 years) combined with prescription of an ACE inhibitor for all persons showing proteinuria and all known diabetics had an ICER of $A4793 per QALY gained. Strategies combining primary care screening of 50- to 69-year-olds for proteinuria, diabetes, and hypertension followed by the routine use of ACE inhibitors, and optimal treatment of diabetes and hypertension, respectively, have the potential to reduce death and end-stage kidney disease and are likely to represent good value for money.
Publisher: Elsevier BV
Date: 03-2022
DOI: 10.1111/AJT.16898
Abstract: Deceased donor kidneys are a scarce community resource therefore, the principles underpinning organ allocation should reflect societal values. This study aimed to elicit community and healthcare professional preferences for principles guiding the allocation of kidneys from deceased donors and compare how these differed across the populations. A best-worst scaling survey including 29 principles in a balanced incomplete block design was conducted among a representative s le of the general community (n = 1237) and healthcare professionals working in transplantation (n = 206). Sequential best-worst multinomial logistic regression was used to derive scaled preference scores (PS) (range 0-100). Thematic analysis of free text responses was performed. Five of the six most valued principles among members of the community related to equity, including priority for the longest waiting (PS 100), difficult to transplant (PS 94.5) and sickest (PS 93.9), and equitable access for men and women (PS 94.0), whereas the top four principles for healthcare professional focused on maximizing utility (PS 89.9-100). Latent class analysis identified unmeasured class membership among community members. There are discordant views between community members and healthcare professionals. These should be considered in the design, evaluation, and implementation of deceased donor kidney allocation protocols.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 27-07-2014
Publisher: Elsevier BV
Date: 04-2011
DOI: 10.1016/J.PEC.2010.05.025
Abstract: This study aimed to develop and pilot test an online screening decision aid (DA) for men with a family history of prostate cancer. Eligible men (with no previous prostate cancer diagnosis) were recruited through relatives attending a urology outpatient clinic. Men evaluated the DA in two stages. First, they appraised a paper-based version using a questionnaire (n=22). Second, the same men were asked to reflect on an interactive web-based version via a semi-structured telephone interview (n=20). Men evaluated both forms of the DA positively. Of the paper-based version, the majority of participants found the DA useful (91%), and that it contained enough information to make a screening decision (73%). All participants reported that the online DA was easy to use and navigate. Most participants reported that a website was their preferred mode of receiving prostate cancer screening information (70%). The developed DA may represent the first online decision-making tool designed specifically for men with a family history prostate cancer that presents age and risk specific information to the user. Comprehensive evaluations of the efficacy and impact of educational interventions such as this are crucial to improve services for in iduals making informed screening decisions.
Publisher: Elsevier BV
Date: 09-2011
DOI: 10.1016/J.YPMED.2011.06.013
Abstract: In current medical literature, mammography and other cancer screening programs are subject to controversy because of debate about the magnitude and nature of the benefits and harms. This paper discusses the issues around informed choice for women considering breast screening. We discuss qualitative and quantitative studies of women's attitudes to breast screening and informed choice. Women view breast screening as a way of avoiding potential regret, and reassurance from normal results is highly valued. Screening participants acknowledge anxiety about false positives but awareness regarding potential overdetection of indolent breast cancer is minimal, and research is needed to assess how better understanding of screening downsides may affect women's views. In any case, weighing up screening advantages and disadvantages is sensitive to personal preferences. Communicators have an ethical obligation to make balanced information available to women, which is flexible enough to respond to the level of detail and involvement desired by each in idual. Many women want to know more and to participate more actively in screening decisions. Techniques have been developed to present balanced information and support in idual decision making in ways that are accessible and empowering for the wider community. Evaluations of breast cancer screening must integrate clinical data with evidence on the perspectives of women themselves.
Publisher: Springer Science and Business Media LLC
Date: 08-01-2019
Publisher: Springer Science and Business Media LLC
Date: 03-11-2020
Publisher: Elsevier BV
Date: 03-2010
DOI: 10.1053/J.AJKD.2009.11.011
Abstract: How patients choose between alternative treatments for kidney failure is poorly understood. Recent studies of chronic kidney disease report that clinical outcomes, such as life expectancy, are rarely reflected in a patient's decision for type of treatment compared with nonclinical outcomes, such as time on dialysis therapy, convenience, or impact on the family. A qualitative analysis using thematic synthesis of patient views about renal replacement therapy (RRT) was undertaken. As part of a national study of patients and renal health care providers, we interviewed 95 Australian dialysis and transplant patients to explore how they perceive these alternative treatments. 52 patients were on satellite hemodialysis therapy, 8 patients were on incenter hemodialysis therapy, 8 patients were on continuous ambulatory peritoneal dialysis therapy, 5 patients were on automated peritoneal dialysis therapy, 4 patients were on home hemodialysis therapy, and 18 patients had a functioning transplant at the time of interview. Freedom, convenience, self-care, effectiveness, and simplicity were commonly cited positive characteristics, whereas confinement, risk, family burden, pain, and time commitment were negative characteristics associated with RRTs. Characteristics were not specific to dialysis modalities, and some (eg, self-care) were seen as both positive and negative. A limitation of the study was that only 17 of 77 (22%) dialysis patients interviewed were on a home-based therapy. Patients preferred RRTs that enhanced their freedom and autonomy and were convenient, effective, and simple. Treatments that minimized confinement and risk also were viewed positively. Our analysis suggests that patients might choose between therapies based on their perception regarding which therapy most embodies particular characteristics that minimize impact on their lifestyle. Presentation of information regarding RRTs should focus on these characteristics and the potential impact of alternative treatments on the patients and how they wish to lead their lives.
Publisher: Wiley
Date: 10-07-2017
DOI: 10.1002/IJC.30858
Abstract: From 2013 through 2017, the Australian national breast cancer screening programme is gradually inviting women aged 70-74 years to attend screening, following a policy decision to extend invitations to older women. We estimate the benefits and harms of the new package of biennial screening from age 50-74 compared with the previous programme of screening from age 50-69. Using a Markov model, we applied estimates of the relative risk reduction for breast cancer mortality and the risk of overdiagnosis from the Independent UK Panel on Breast Cancer Screening review to Australian breast cancer incidence and mortality data. We estimated screening specific outcomes (recalls for further imaging, biopsies, false positives, and interval cancer rates) from data published by BreastScreen Australia. When compared with stopping at age 69, screening 1,000 women to age 74 is likely to avert one more breast cancer death, with an additional 78 women receiving a false positive result and another 28 women diagnosed with breast cancer, of whom eight will be overdiagnosed and overtreated. The extra 5 years of screening results in approximately 7 more overdiagnosed cancers to avert one more breast cancer death. Thus extending screening mammography in Australia to older women results in a less favourable harm to benefit ratio than stopping at age 69. Supporting informed decision making for this age group should be a public health priority.
Publisher: Elsevier BV
Date: 03-2011
DOI: 10.1053/J.AJKD.2011.08.024
Abstract: It is unclear how many incident patients with stage 5 chronic kidney disease (CKD) referred to nephrologists are presented with information about conservative care as a treatment option and how many plan not to dialyze. National observational survey study with random-effects logistic regression. Incident adult and pediatric pre-emptive transplant, dialysis, and conservative-care patients from public and private renal units in Australia, July to September 2009. Age, sex, health insurance status, language, time known to nephrologist, timing of information, presence of caregiver, unit conservative care pathway, and size of unit. The 2 main outcome measures were information provision to incident patients about conservative care and initial treatment regardless of planned conservative care. 66 of 73 renal units (90%) participated. 10 (15%) had a formal conservative-care pathway. Of 721 incident patients with stage 5 CKD, 470 (65%) were presented with conservative care as a treatment option and 102 (14%) planned not to dialyze median age was 80 years. Multivariate analysis for information provision showed that patients older than 65 years (OR, 3.40 95% CI, 1.97-5.87) and those known to a nephrologist for more than 3 months (OR, 6.50 95% CI, 3.18-13.30) were more likely to receive information about conservative care. Patients with conservative care as planned initial treatment were more likely to be older than 65 years (OR, 4.71 95% CI, 1.77-12.49) and women (OR, 2.23 95% CI, 1.23-4.02) than those who started dialysis therapy. Those with private health insurance were less likely to forgo dialysis therapy (OR, 0.40 95% CI, 0.17-0.98). Cross-sectional design prohibited longer term outcome measurement. Excluded patients with stage 5 CKD managed in the community. 1 in 7 patients with stage 5 CKD referred to nephrologists plans not to dialyze. Comprehensive service provision with integrated palliative care needs to be improved to meet the demands of the aging population.
Publisher: American Medical Association (AMA)
Date: 07-0005
Publisher: Elsevier BV
Date: 2015
DOI: 10.1016/J.JAMDA.2014.07.006
Abstract: To compare the costs and cost-effectiveness of a multifactorial interdisciplinary intervention versus usual care for older people who are frail. Cost-effectiveness study embedded within a randomized controlled trial. Community-based intervention in Sydney, Australia. A total of 241 community-dwelling people 70 years or older who met the Cardiovascular Health Study criteria for frailty. A 12-month multifactorial, interdisciplinary intervention targeting identified frailty characteristics versus usual care. Health and social service use, frailty, and health-related quality of life (EQ-5D) were measured over the 12-month intervention period. The difference between the mean cost per person for 12 months in the intervention and control groups (incremental cost) and the ratio between incremental cost and effectiveness were calculated. A total of 216 participants (90%) completed the study. The prevalence of frailty was 14.7% lower in the intervention group compared with the control group at 12 months (95% CI 2.4%-27.0% P = .02). There was no significant between-group difference in EQ-5D utility scores. The cost for 1 extra person to transition out of frailty was $A15,955 (at 2011 prices). In the "very frail" subgroup (participants met >3 Cardiovascular Health Study frailty criteria), the intervention was both more effective and less costly than the control. A cost-effectiveness acceptability curve shows that the intervention would be cost-effective with 80% certainty if decision makers were willing to pay $A50,000 per extra person transitioning from frailty. In the very frail subpopulation, this reduced to $25,000. For frail older people residing in the community, a 12-month multifactorial intervention provided better value for money than usual care, particularly for the very frail, in whom it has a high probability of being cost saving, as well as effective. Trial registration: ACTRN12608000250336.
Publisher: BMJ
Date: 02-12-2019
DOI: 10.1136/BJSPORTS-2019-101512
Abstract: To assess the effects of exercise interventions for preventing falls in older people living in the community. We included randomised controlled trials evaluating the effects of any form of exercise as a single intervention on falls in people aged 60+years living in the community. Exercise reduces the rate of falls by 23% (rate ratio (RaR) 0.77, 95% CI 0.71 to 0.83 12 981 participants, 59 studies high-certainty evidence). Subgroup analyses showed no evidence of a difference in effect on falls on the basis of risk of falling as a trial inclusion criterion, participant age 75 years+ or group versus in idual exercise but revealed a larger effect of exercise in trials where interventions were delivered by a health professional (usually a physiotherapist). Different forms of exercise had different impacts on falls. Compared with control, balance and functional exercises reduce the rate of falls by 24% (RaR 0.76, 95% CI 0.70 to 0.81 7920 participants, 39 studies high-certainty evidence). Multiple types of exercise (commonly balance and functional exercises plus resistance exercises) probably reduce the rate of falls by 34% (RaR 0.66, 95% CI 0.50 to 0.88 1374 participants, 11 studies moderate-certainty evidence). Tai Chi may reduce the rate of falls by 19% (RaR 0.81, 95% CI 0.67 to 0.99 2655 participants, 7 studies low-certainty evidence). We are uncertain of the effects of programmes that primarily involve resistance training, dance or walking. Given the certainty of evidence, effective programmes should now be implemented.
Publisher: Wiley
Date: 10-08-2021
DOI: 10.1111/JHN.12937
Abstract: There is little information available to inform the cost‐effectiveness of eHealth interventions in improving patient health outcomes. A trial‐based economic evaluation was undertaken aiming to inform the feasibility of conducting a mobile phone text messaging programme targeting dietary behaviours in people receiving haemodialysis. A trial‐based economic evaluation from a health system perspective of a 6‐month pilot randomised controlled trial was undertaken. One hundred and thirty patients receiving haemodialysis from six dialysis units across Sydney, Australia, were enrolled into the KIDNEYTEXT study. Usual care (inperson dietary counselling) was compared with usual care plus three semi‐personalised dietary mobile phone text messages per week over a 6‐month period. The outcomes of this economic evaluation included: cost of intervention, cost‐effectiveness and marginal effects on total costs. The cost of developing and maintaining the KIDNEYTEXT intervention was US $110 per participant. Total costs were US $1418 higher in the usual care arm compared to the intervention arm. The incremental benefits for quality‐adjusted life adjusted years were 0.01 [95% confidence interval (CI) = −0.03 to 0.06] and dietary adherence (i.e., adherent to three or more dietary guidelines at 6 months) being 0.04 (95% CI = −0.15 to 0.24). The largest component of total costs was related to unplanned admissions to hospital. Mobile phone text messages targeting dietary behaviours may be cost saving, at the same time as maintaining similar or improved dietary behaviours. A larger trial with a longer follow‐up time is warranted.
Publisher: American Association for Cancer Research (AACR)
Date: 30-06-2016
DOI: 10.1158/1055-9965.EPI-15-1106
Abstract: Background: There is debate about the accuracy of anal cytology and high-resolution anoscopy (HRA), in the diagnosis of anal human papillomavirus (HPV)-related squamous intraepithelial lesions (SIL). Few studies have performed both simultaneously in a large s le of high-risk in iduals. Methods: At baseline in a community-based cohort of HIV-infected and uninfected homosexual men ages ≥35 years in Sydney, Australia, all men underwent anal swabbing for cytology and HPV genotyping, and HRA-guided biopsy. We evaluated the separate and combined diagnostic accuracy of cytology and histology, based on a comparison with the prevalence of HPV16 and other high-risk (HR) HPV. We examined trends in HPV prevalence across cytology–histology combinations. Results: Anal swab, HRA, and HPV genotyping results were available for 605 of 617 participants. The prevalence of cytologically predicted high-grade SIL (HSIL, 17.9%) was lower than histologically diagnosed HSIL (31.7%, P & 0.001). The prevalence of composite-HSIL (detected by either method) was 37.7%. HPV16 prevalence was similar in men with HSIL by cytology (59.3%), HSIL by histology (51.0%), and composite-HSIL (50.0%). HPV16 prevalence was 31.1% in men with composite-atypical squamous cells suggestive of HSIL, to 18.5% in men with composite-low-grade SIL, to 12.1% in men with composite-negative results (Ptrend & 0.001). Conclusions: Significantly more HSIL was detected when a composite cytology–histology endpoint was used. Increasing grade of composite endpoint was associated with increasing HPV16 prevalence. Impact: These data suggest that a composite cytology–histology endpoint reflects meaningful disease categories and is likely to be an important biomarker in anal cancer prevention. Cancer Epidemiol Biomarkers Prev 25(7) 1134–43. ©2016 AACR.
Publisher: Informa UK Limited
Date: 02-2017
DOI: 10.2147/CEOR.S69340
Publisher: Public Library of Science (PLoS)
Date: 16-08-2010
Publisher: Oxford University Press (OUP)
Date: 10-09-2017
Abstract: To estimate the effect of factors that influence decisions to transfer residents of aged care facilities to an emergency department (ED) for acute medical emergencies. A discrete choice experiment with residents (N = 149), the relatives of residents (N = 137) and staff members (N = 128) of aged care facilities. Aged care facilities in three Australian states. Using random parameter logit models, parameter estimates and odds ratios were estimated, and resultant utility functions for ED and alternate care were constructed. All attributes (including waiting time, complication rates, symptom relief and time spent alone) significantly influence choice for accessing acute care. There is a strong overall preference for ED care (odds ratio 1.73, 95% confidence interval 1.57–1.92), but this varies by clinical scenario, being the strongest for pneumonia and weakest for wrist fracture. Relatives of residents were less tolerant of reductions in care quality than staff members or residents themselves. Underlying preference for ED transfer of aged care facility residents in acute medical emergencies is strong and independent of commonly used quality of care measures.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2017
Publisher: Elsevier BV
Date: 07-2012
DOI: 10.1053/J.AJKD.2011.12.030
Abstract: Dialysis modality preferences of patients with chronic kidney disease (CKD) and family caregivers are important, yet rarely quantified. Prospective, unlabeled, discrete-choice experiment with random-parameter logit analysis. Adults with stages 3-5 CKD and caregivers educated about dialysis treatment options from 8 Australian renal clinics. Preferences for and trade-offs between the dialysis treatment attributes of life expectancy, number of hospital visits per week, ability to travel, hours per treatment, treatment time of day, subsidized transport service, and flexibility of treatment schedule. Results presented as ORs for preferring home-based or in-center dialysis to conservative care. 105 predialysis patients and 73 family caregivers completed the study. Median patient age was 63 years, and mean estimated glomerular filtration rate was 18.1 (range, 6-34) mL/min/1.73 m(2). Median caregiver age was 61 years. Home-based dialysis (either peritoneal or home hemodialysis) was chosen by patients in 65% of choice sets in-center dialysis, in 35% and conservative care, in 10%. For caregivers, this was 72%, 25%, and 3%, respectively. Both patients and caregivers preferred longer rather than shorter hours of dialysis (ORs of 2.02 [95% CI, 1.51-2.70] and 2.67 [95% CI, 1.85-3.85] for patients and caregivers, respectively), but were less likely to choose nocturnal than daytime dialysis (ORs of 0.07 [95% CI, 0.01-0.75] and 0.03 [95% CI, 0.01-0.20]). Patients were willing to forgo 23 (95% CI, 19-27) months of life expectancy with home-based dialysis to decrease their travel restrictions. For caregivers, this was 17 (95% CI, 16-18) patient-months. Data were limited to stated preferences rather than actual choice of dialysis modality. Our study suggests that it is rare for caregivers to prefer conservative nondialytic care for family members with CKD. Home-based dialysis modalities that enable patients and their family members to travel with minimal restriction would be strongly aligned with the preferences of both parties.
Publisher: Springer Science and Business Media LLC
Date: 06-11-2010
DOI: 10.1007/S10552-009-9459-Z
Abstract: To estimate the extent of overdiagnosis of invasive breast cancer associated with screening in New South Wales, Australia, a population with a well-established mammography screening program which has achieved full geographic coverage. We calculated overdiagnosis as the observed annual incidence of invasive breast cancer in NSW in 1999-2001 (a screened population) minus the expected annual incidence in this population at the same time, as a percentage of the expected incidence. We estimated expected incidence without screening in 1999-2001 from the incidence of invasive breast cancer in: (1) women in unscreened age groups (interpolation method) and (2) women in all age groups prior to the implementation of screening (extrapolation method). We then adjusted these estimates for trends in major risk factors for breast cancer that may have coincided with the introduction of mammography screening: increasing obesity, use of hormone replacement therapy (HRT) and nulliparity. Finally, we adjusted for lead time to produce estimates of expected incidence in 1999-2001. These were compared with the observed incidence in 1999-2001 to calculate overdiagnosis of breast cancer associated with screening. Overdiagnosis of invasive breast cancer among 50-69 year NSW women was estimated to be 42 and 30% using the interpolation and extrapolation methods, respectively. Overdiagnosis of invasive breast cancer attributable to mammography screening appears to be substantial. Our estimates are similar to recent estimates from other screening programmes. Overdiagnosis merits greater attention in research and in clinical and public health policy making.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2017
Publisher: American Psychological Association (APA)
Date: 2014
DOI: 10.1037/A0034405
Abstract: This study examines the efficacy of an online screening decision aid (DA) for men with a family history of prostate cancer. Unaffected Australian men (40-79 years) with at least one affected relative completed the first online questionnaire, were randomized to read either the tailored DA (intervention) or nontailored information about prostate cancer screening (control), then completed a questionnaire postreading and 12 months later. The primary outcome was decisional conflict regarding prostate specific antigen (PSA) testing. The impact of the DA on longitudinal outcomes was analyzed by using random intercept mixed effects models. Logistic and linear regressions were used to analyze the impact of the DA on screening behavior and decision regret. Stage of decision-making was tested as a moderator for decisional conflict and decision regret. The frequency of online material access was recorded. The DA had no effect on decisional conflict, knowledge, inclination toward PSA testing, accuracy of perceived risk, or screening behavior. However, among men considering PSA testing, those who read the DA had lower decision regret compared with men who read the control materials, β = 0.34, p < .001, 95% confidence interval (CI) = [.22, .53]. This is the first study to our knowledge to evaluate the uptake and efficacy of an online screening DA among men with a family history of prostate cancer. Men who were undecided about screening at baseline benefitted from the DA, experiencing less regret 12 months later. In relation to decisional conflict, the control materials may have operated as a less complex and equally informative DA.
Publisher: Elsevier BV
Date: 03-2015
DOI: 10.1053/J.AJKD.2014.10.020
Abstract: Although home hemodialysis (HD) is associated with better survival compared with hospital HD, the burden of treatment may be intensified for patients and their caregivers and deter patients from this treatment choice. We describe patient and caregiver perspectives and experiences of home HD to inform home HD programs that align with patient preferences. Systematic review of qualitative studies. Adults with chronic kidney disease and caregivers of both home and hospital dialysis patients who expressed opinions about home HD. MEDLINE, EMBASE, PsycINFO, CINAHL, and reference lists were searched to October 2013. Thematic synthesis. 24 studies involving 221 patients (home HD [n=109], hospital HD [n=97], and predialysis [n=15]) and 121 caregivers were eligible. We identified 5 themes: vulnerability of dialyzing independently (fear of self-needling, feeling unqualified, and anticipating catastrophic complications), fear of being alone (social isolation and medical disconnection), concern of family burden (emotional demands on caregivers, imposing responsibility, family involvement, and medicalizing the home), opportunity to thrive (re-establishing a healthy self-identity, gaining control and freedom, strengthening relationships, experiencing improved health, and ownership of decision), and appreciating medical responsiveness (attentive monitoring and communication, depending on learning and support, developing readiness, and clinician validation). Non-English articles were excluded. Patients and caregivers perceive that home HD offers the opportunity to thrive improves freedom, flexibility, and well-being and strengthens relationships. However, some voice anxiety and fear about starting home HD due to the confronting nature of the treatment and isolation from medical and social support. Acknowledging and addressing these apprehensions can improve the delivery of predialysis and home HD programs to better support patients and caregivers considering home HD.
Publisher: Elsevier BV
Date: 2018
DOI: 10.1016/J.JPHYS.2017.11.011
Abstract: Among people admitted for inpatient rehabilitation, is usual care plus standing balance circuit classes more cost-effective than usual care alone? Cost-effectiveness study embedded within a randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. 162 rehabilitation inpatients from a metropolitan hospital in Sydney, Australia. The experimental group received a 1-hour standing balance circuit class, delivered three times a week for 2 weeks, in addition to usual therapy. The circuit classes were supervised by one physiotherapist and one physiotherapy assistant for up to eight patients. The control group received usual therapy alone. Costs were estimated from routinely collected hospital use data in the 3 months after randomisation. The functional outcome measure was mobility measured at 3 months using the Short Physical Performance Battery administered by a blinded assessor. An incremental analysis was conducted and the joint probability distribution of costs and outcomes was examined using bootstrapping. The median cost savings for the intervention group was AUD4,741 (95% CI 137 to 9,372) per participant 94% of bootstraps showed that the intervention was both effective and cost saving. Two weeks of additional standing balance circuit classes delivered in addition to usual therapy resulted in decreased healthcare costs at 3 months in hospital inpatients admitted for rehabilitation. There is a high probability that this intervention is both cost saving and effective. ACTRN12611000412932. [Treacy D, Howard K, Hayes A, Hassett L, Schurr K, Sherrington C (2018) Two weeks of additional standing balance circuit classes during inpatient rehabilitation are cost saving and effective: an economic evaluation. Journal of Physiotherapy 64: 41-47].
Publisher: Elsevier BV
Date: 12-2007
DOI: 10.1016/J.CGH.2007.09.003
Abstract: Computerized tomography colonography (CTC) is a highly accurate test for the detection of colorectal polyps and cancers and has been proposed as a potential alternative to colonoscopy. Bowel cancer screening using fecal occult blood testing (FOBT) and follow-up diagnostic colonoscopy is an effective intervention that currently is being implemented in screening programs internationally. Because of high false-positive rates for FOBT, concerns have been raised about patient uptake and access to colonoscopy services. This study assessed the value of CTC as an alternative to colonoscopy in FOBT-positive in iduals. A systematic review of studies comparing the accuracy of CTC and colonoscopy for the detection of lesions 10 mm or greater and cancers in nonscreening populations was conducted. A modeled economic analysis was undertaken to assess cost per life-year saved. Five eligible studies were identified. Pooled sensitivity and specificity for the detection of lesions 10 mm or greater were 63% (95% confidence interval [CI], 55%-71%) and 95% (95% CI, 94%-97%) for CTC, and 95% (95% CI, 90%-98%) and 99.8% (95% CI, 99.5%-100%) for colonoscopy, respectively (3 studies). Pooled sensitivity and specificity for the detection of cancer were 89% (95% CI, 70%-98%) and 97% (95% CI, 95%-98%) for CTC, and 96% (95% CI, 80%-100%) and 99.7% (95% CI, 99%-100%) for colonoscopy, respectively (3 studies). The base case economic analysis showed that CTC is less effective and more costly than colonoscopy. At a low prevalence of polyps, sensitivity analysis found CTC was less effective and less costly than colonoscopy if CTC was more sensitive than colonoscopy, CTC was more effective, at higher cost. Overall, CTC appears less accurate, less effective, and potentially more costly than colonoscopy in in iduals with a positive FOBT.
Publisher: Elsevier BV
Date: 10-2017
DOI: 10.1053/J.AJKD.2016.11.029
Abstract: Survival and quality of life for patients on hemodialysis therapy remain poor despite substantial research efforts. Existing trials often report surrogate outcomes that may not be relevant to patients and clinicians. The aim of this project was to generate a consensus-based prioritized list of core outcomes for trials in hemodialysis. In a Delphi survey, participants rated the importance of outcomes using a 9-point Likert scale in round 1 and then re-rated outcomes in rounds 2 and 3 after reviewing other respondents' scores. For each outcome, the median, mean, and proportion rating as 7 to 9 (critically important) were calculated. 1,181 participants (202 [17%] patients/caregivers, 979 health professionals) from 73 countries completed round 1, with 838 (71%) completing round 3. Outcomes included in the potential core outcome set met the following criteria for both patients/caregivers and health professionals: median score ≥ 8, mean score ≥ 7.5, proportion rating the outcome as critically important ≥ 75%, and median score in the forced ranking question < 10. Patients/caregivers rated 4 outcomes higher than health professionals: ability to travel, dialysis-free time, dialysis adequacy, and washed out after dialysis (mean differences of 0.9, 0.5, 0.3, and 0.2, respectively). Health professionals gave a higher rating for mortality, hospitalization, decrease in blood pressure, vascular access complications, depression, cardiovascular disease, target weight, infection, and potassium (mean differences of 1.0, 1.0, 1.0, 0.9, 0.9, 0.8, 0.7, 0.4, and 0.4, respectively). The Delphi survey was conducted online in English and excludes participants without access to a computer and internet connection. Patients/caregivers gave higher priority to lifestyle-related outcomes than health professionals. The prioritized outcomes for both groups were vascular access problems, dialysis adequacy, fatigue, cardiovascular disease, and mortality. This process will inform a core outcome set that in turn will improve the relevance, efficiency, and comparability of trial evidence to facilitate treatment decisions.
Publisher: SAGE Publications
Date: 06-2005
Abstract: Background: In many countries high participation is an explicit target in screening programmes. The desire for high participation often appears to drive screening policy, although it is increasingly recognized that encouraging high participation may impinge upon the rights of an in idual to make an informed choice. One argument offered in support of high participation is that it improves the cost-effectiveness of screening. This is questionable on theoretical grounds, and empirically there are conflicting results. Two recent cost-effectiveness models of faecal occult blood test (FOBT) screening for colorectal cancer (CRC) showed that cost-effectiveness was improved, another showed that cost-effectiveness was worsened and a fourth indicated that cost-effectiveness was unaffected by increasing the participation rate. Methods: We assessed the extent to which different levels and patterns of participation affect cost-effectiveness, using decision modelling of three CRC screening with FOBT scenarios. We estimate the incremental cost-effectiveness (value for money) ratios for each scenario. Results: The way in which participation is modelled, particularly assumptions made about the subsequent screening behaviour of non-participants ('if' and 'when' a non-participant attends for subsequent screening), affects the cost-effectiveness estimates for FOBT screening programmes. 100% participation in all screening rounds gives a cost per life year saved (LYS) of US& dollar . Cost-effectiveness is worst when people who do not take part in one screening round (initial or subsequent) never take part in any future rounds of screening. Under this scenario, a participation rate of 20% in second and subsequent rounds gives a cost per LYS of US& dollar ,500. Under more realistic assumptions, for ex le the attendance of even a small proportion of non-participants in subsequent rounds, cost-effectiveness is more favourable and similar to that achieved for full participation: the scenario with a random participation rate of 20% in second and subsequent rounds for both participants and non-participants has a cost per LYS of US& dollar ,270. Conclusions: Contrary to a commonly held view, high participation in screening programmes is not necessary to achieve cost-effectiveness. Setting high target participation rates in screening programmes does not guarantee cost-effectiveness and may in certain circumstances reduce the cost-effectiveness.
Publisher: SAGE Publications
Date: 17-01-2020
Abstract: There is substantial variation in peritonitis rates across peritoneal dialysis (PD) units globally. This may, in part, be related to the wide variability in the content and delivery of training for PD nurse trainers and patients. The aim of this study was to test the feasibility of implementing the Targeted Education ApproaCH to improve Peritoneal Dialysis Outcomes (TEACH-PD) curriculum in real clinical practice settings. This study used mixed methods including questionnaires and semi-structured interviews (pretraining and post-training) with nurse trainers and patients to test the acceptability and usability of the PD training modules implemented in two PD units over 6 months. Quantitative data from the questionnaires were analysed descriptively. Interviews were analysed using thematic analysis. Ten PD trainers and 14 incident PD patients were included. Mean training duration to complete the modules were 10.9 h (range 6–17) and 24.9 h (range 15–35), for PD trainers and patients, respectively. None of the PD patients experienced PD-related complications at 30 days follow-up. Three (21%) patients were transferred to haemodialysis due to non-PD–related complications. Ten trainers and 14 PD patients participated in the interviews. Four themes were identified including use of adult learning principles (trainers), comprehension of online modules (trainers), time to complete the modules (trainers) and patient usability of the manuals (patient). This TEACH-PD study has demonstrated feasibility of implementation in a real clinical setting. The outcomes of this study have informed refinement of the TEACH-PD modules prior to rigorous evaluation of its efficacy and cost-effectiveness in a large-scale study.
Publisher: Elsevier BV
Date: 09-2016
Publisher: Springer Science and Business Media LLC
Date: 03-2012
DOI: 10.1038/BJC.2012.62
Publisher: Springer Science and Business Media LLC
Date: 14-07-2015
Publisher: Springer Science and Business Media LLC
Date: 19-10-2020
Publisher: Wiley
Date: 17-06-2022
DOI: 10.1002/HPJA.624
Abstract: The lack of evidence on the priorities of carers and their Aboriginal and Torres Strait Islander children undermines decisions to improve participant experiences and engagement. This study describes carer and staff perspectives on the aspects of health services delivery that are important to carers and children. Nineteen carers of Aboriginal and Torres Strait Islander children and 17 staff who work at child health programs across two urban Aboriginal Community Controlled Health Services (ACCHSs) and affiliate organisations in New South Wales, Australia participated in semi‐structured interviews. We used thematic analysis to analyse the data. We identified five themes: valuing relational communication (building trust by keeping relationships at the centre, empowered to optimise child's development, feeling heard and known) confidence in provider's clinical and interpersonal skills (certain that the health issue will be resolved, engaging with the child to allay fears, facilitating timely health care) finding comfort and security in community embedded services (safety and acceptance in the familiar, strengthening child's connection to culture) support to access and navigate health services (accessible information appropriately presented, easy and flexible scheduling, easing the shame of financial hardship) sustaining service use (fulfilling expectations for service standards, demonstrating commitment through ongoing programs, clarity of benefits). Carers and staff reported that approaches to communication, the content of that communication, how access is facilitated and the service environment managed influences their decisions to interact with health services. With these data decision‐makers can better focus resources to improve experiences with their services.
Publisher: Oxford University Press (OUP)
Date: 02-2017
DOI: 10.1093/NDT/GFW436
Abstract: Discrete choice experiment (DCE), conjoint analysis or adaptive conjoint analysis methods are increasingly applied to obtain patient, clinician or community preferences in nephrology. This study systematically reviews the above-mentioned published choice studies providing an overview of the issues addressed, methods and findings. Choice studies relating to nephrology were identified using electronic databases, including Medline, Embase, PsychINFO and Econlit from 1990 to 2015. For inclusion in the review, studies had to primarily relate to kidney disease and include results from statistical (econometric) analyses of respondents' choice or preference. Studies meeting the inclusion criteria were assessed against a range of systematic review criteria, and methods and results summarized. We identified 14 eligible studies from Europe, Australasia, North America and Asia, reporting preferences for treatment or screening, patient experiences, quality of life (QOL), health outcomes and priority-setting frameworks. Specific contexts included medical interventions in kidney transplantation and renal cell carcinoma, health policies for organ donation and allocation, dialysis modalities and end-of-life care, using a variety of statistical models. The characteristics of 'time' (i.e. transplant waiting time, dialysis hours, transport time) and QOL (pre- and post-transplant, or pre- and post-dialysis) consistently influenced patient and clinician preferences across the choice studies. DCE are increasingly used to obtain information about key preferences in kidney transplantation and dialysis. These study methods provide quantitative information about respondents' trade-offs between conflicting clinical and policy objectives, and can establish how preferences vary among stakeholder groups.
Publisher: Springer Science and Business Media LLC
Date: 29-06-2011
Publisher: Oxford University Press (OUP)
Date: 23-07-2014
DOI: 10.1093/NDT/GFU257
Abstract: Nephrologists often face difficult decisions when recommending dialysis or non-dialysis (supportive) care for elderly patients, given the uncertainty around survival and the burden of dialysis. Discrete choice experiments (DCEs) mimic real-world decisions through simultaneous consideration of multiple variables. We aimed to determine the relative influence of patient characteristics on dialysis recommendations. We conducted a DCE among Australasian nephrologists consisting of 12 scenarios of two patients (described in terms of age, gender, cognition, comorbidity, life expectancy, current quality of life (QOL), expected QOL with dialysis, social support, patient and family inclination). Nephrologists indicated which patient they preferred recommending dialysis for, or whether they preferred 'neither'. Mixed logit models determined the odds of recommending dialysis over no dialysis. Trade-offs between QOL and survival were calculated. A total of 159 nephrologists participated (34% aged 40-49 years, 62% male and 69% Caucasian). All patient characteristics except gender significantly affected the likelihood of dialysis recommendation. Nephrologists were more likely to recommend dialysis for patients with preserved cognition (odds ratio [OR]: 68.3 95% confidence interval [CI]: 33.4-140.0), lower comorbidity (OR: 2.1 95% CI: 1.1-4.1), increased life expectancy (OR: 2.8 95% CI: 2.1-3.7), high current QOL (OR: 2.8 95% CI: 2.0-3.8) and positive patient and family dialysis inclination (OR: 27.5 95% CI: 16.2-46.8 and OR: 2.0 95% CI: 1.3-3.3, respectively). Nephrologists aged >65 were more likely (OR: 11.7 95% CI: 1.8-77.2) to recommend dialysis. Nephrologists were willing to forgo 12 months of patient survival to avoid substantial QOL decrease with dialysis. Nephrologists avoided dialysis recommendation if it was expected to considerably reduce QOL. To inform elderly patients' dialysis decisions, systematic and longitudinal cognition and QOL evaluations are needed as well as better research into understanding patient preferences.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2018
Publisher: Elsevier BV
Date: 11-2011
DOI: 10.1053/J.AJKD.2011.05.029
Abstract: Deceased donor kidneys are a scarce resource and there is debate about how to maximize the benefit from each donated kidney while ensuring equity of access to transplants. Allocation of kidneys to waitlisted patients is determined by a computer algorithm, but the decision to waitlist patients or accept the kidneys offered is largely at the discretion of nephrologists. This study aims to elicit nephrologists' perspectives on waitlisting patients for kidney transplant and the allocation of deceased kidneys. We conducted semistructured face-to-face interviews with adult and pediatric nephrologists from 15 Australian nephrology or transplant centers. Transcripts were analyzed for descriptive and analytical themes. 25 nephrologists participated. 5 major themes on waitlisting and deceased donor kidney allocation were identified: patient advocacy (ch ioning their own patients, empowering patients, giving hope, in idualizing judgments, patient preferences, and limited autonomy), professional and moral integrity (transparency, avoiding value judgments, and eliminating bias), protecting center reputation (gatekeeping), achieving equity (uniformity, avoiding discrimination, and fairness for specific populations), and maximizing societal benefit (prioritizing best use of kidney, resource implications, favoring social contribution, and improving efficiency of the allocation process). In making in idual patient assessments, estimates about outcomes for a patient had to be resolved with whether it was reasonable from a broader societal perspective. Nephrologists expressed their primary responsibility in terms of giving their own patients access to a transplant and upholding professional integrity by maintaining transparency and avoiding value judgments and bias. However, nephrologists perceived an obligation to protect their center's reputation through the selection of "good" patients, and this caused some frustration. Despite having personal preferences for optimizing the balance between societal benefit and equity, nephrologists did not want direct responsibility for ensuring societal benefit in clinical practice. Rather, they placed the onus on policy makers and the community to reconcile such tensions and advocate for societal benefit.
Publisher: BMJ
Date: 13-01-2015
DOI: 10.1136/BJSPORTS-2014-094015
Abstract: Physical inactivity accounts for 9% of all deaths worldwide and is among the top 10 risk factors for global disease burden. Nearly half of people aged over 60 years are inactive. Efforts to identify which factors influence physical activity behaviour are needed. To identify and synthesise the range of barriers and facilitators to physical activity participation. Systematic review of qualitative studies on the perspectives of physical activity among people aged 60 years and over. MEDLINE, EMBASE, CINAHL, PsychINFO and AMED were searched. Independent raters assessed comprehensiveness of reporting of included studies. Thematic synthesis was used to analyse the data. From 132 studies involving 5987 participants, we identified six major themes: social influences (valuing interaction with peers, social awkwardness, encouragement from others, dependence on professional instruction) physical limitations (pain or discomfort, concerns about falling, comorbidities) competing priorities access difficulties (environmental barriers, affordability) personal benefits of physical activity (strength, balance and flexibility, self-confidence, independence, improved health and mental well-being) and motivation and beliefs (apathy, irrelevance and inefficacy, maintaining habits). Some older people still believe that physical activity is unnecessary or even potentially harmful. Others recognise the benefits of physical activity, but report a range of barriers to physical activity participation. Strategies to enhance physical activity participation among older people should include (1) raising awareness of the benefits and minimise the perceived risks of physical activity and (2) improving the environmental and financial access to physical activity opportunities.
Publisher: Springer Science and Business Media LLC
Date: 04-04-2014
Publisher: AMPCo
Date: 11-2005
DOI: 10.5694/J.1326-5377.2005.TB07124.X
Abstract: To compare the safety, effectiveness and cost-effectiveness of drug-eluting coronary stents used in Australia with bare-metal stents and determine whether the benefits are greater for high-risk subgroups. MEDLINE, Pre-Medline, EMBASE, Current Contents, CINAHL and the Cochrane Library database were searched to identify eligible randomised controlled trials and systematic reviews published in English between January 1966 and June 2004. Seven randomised controlled trials that assessed polymer-based paclitaxel- or sirolimus-eluting stents versus bare-metal stents in patients with coronary atherosclerosis and reported on stent thrombosis, mortality, myocardial infarction, coronary artery bypass grafting or target lesion revascularisation. Two independent reviewers appraised eligible studies and extracted data. Relative risks (RRs) were calculated for each outcome and pooled using the Mantel-Haenszel method. Rates of stent thrombosis, mortality, myocardial infarction and bypass grafts did not differ by stent type. Drug-eluting stents (DESs) resulted in a 71%-80% lower risk of revascularisation at 12 months (RR 0.29 [95% CI, 0.20-0.43] for paclitaxel-eluting stents [n = 1593 patients] RR 0.20 [95% CI, 0.13-0.29] for sirolimus-eluting stents [n = 1296 patients]). Similar benefits were seen in several high-risk subgroups of patients: those with diabetes, lesion length > 20 mm and target-vessel diameter < or = 2.5 mm. The benefits of DESs in these high-risk groups over lower-risk groups were inconclusive because of low numbers. The cost per revascularisation avoided by using DESs was 3,750-6,100 Australian dollars, with an estimated cost per quality-adjusted-life-year (QALY) gained of 46,829-76,467 Australian dollars. In sensitivity analyses, estimates varied from DESs being cost-saving to costing an additional 314,385 Australian dollars per QALY gained. DESs are effective in reducing revascularisation. Estimates of cost-effectiveness are very sensitive to changes in estimates of their true effects in clinical practice, market price and the number of stents used per patient. Decisions to limit DESs to only patients at the highest risk of restenosis may improve their cost-effectiveness but will need to be reassessed when evidence is available to compare absolute benefits between patient groups.
Publisher: Public Library of Science (PLoS)
Date: 19-10-2022
DOI: 10.1371/JOURNAL.PONE.0276141
Abstract: Several disciplines, among them health, sociology, and economics, provide strong evidence that social context is important to in idual choices. It is therefore surprising that relatively little research has been focused on integrating the effect of social influence into choice models, especially given the importance of such choices in healthcare. This study developed and empirically tested a choice model that accounts for social network influences in a discrete choice experiment (DCE). We focused on maternal choices for childhood vaccination in Australia, and used an econometric choice model that explicitly 1) incorporated vaccine schedule characteristics, benefits and costs, and 2) represented up to ten different identifiable key influencer types (e.g., partner, parents, friends, healthcare professionals, inter alia ), allowing for the attribution of directional importance of each influencer on the gravid woman’s decision to adhere to or reject childhood vaccination. Pregnant women (N = 604) aged 18 years and older recruited from an online panel completed a survey, including a DCE and questions about key influencers. A two-class ordered latent class model was conducted to analyse the DCE data, which assumes that the underlying latent driver (in our case the WHO vaccine hesitancy scale) is ordered, to give a practical interpretation of the meaning of the classes. When the choice model considered both childhood vaccination attributes and key influencers, a very high model fit was reached. The impact of key influencers on maternal choice for childhood vaccination was massive compared to the impact of childhood vaccination attributes. The marginal impact differed between key influencers. Our DCE study showed that the maternal decision for childhood vaccination was essentially almost completely socially driven, suggesting that the potential impact of social network influences can and should be considered in health-related DCEs, particular those where there are likely to be strong underlying social norms dictating decision maker behaviour.
Publisher: Wiley
Date: 23-09-2015
DOI: 10.1002/MDS.26420
Abstract: The aim of this study was to determine the cost-effectiveness of a 6-month minimally supervised exercise program for people with PD. An economic analysis was conducted alongside a randomized, controlled trial in which 231 people age 40 years and over with PD were randomized into a usual care control group or an exercise group. Cost-effectiveness was estimated using incremental cost per fall prevented (using falls calendars) as the primary analysis and cost per extra person avoiding mobility deterioration (defined as an improvement or no change in the 12-point Short Physical Performance Battery Score between baseline and 6 month). A cost-utility analysis using the Short Form-6D was also performed. Uncertainty was represented using cost-effectiveness scatter plots and acceptability curves. Planned subgroup analyses for the low-disease-severity group were also undertaken. All results are reported in Australian dollars ($A). The average cost of the intervention was $A1,010 per participant. Incremental cost-effectiveness of the program relative to usual care was $A574 per fall prevented, $A9,570 per extra person avoiding mobility deterioration, and $A338,800 per quality-adjusted life year gained. The intervention had an 80% probability of being cost-effective, relative to the control, at a threshold of $A2,000 per fall prevented. Subgroup analyses for the low-disease-severity group indicate the program to be dominant, that is, less costly and more effective than usual care for all health outcomes. The exercise intervention appeared cost-effective with regard to fall prevention in the whole s le and cost saving in the low disease severity group, when compared with usual care.
Publisher: Elsevier BV
Date: 03-2022
DOI: 10.1053/J.JRN.2021.02.006
Abstract: Effect of dietetic consultation (DC) on clinical outcomes is an under-researched component of predialysis education. Predialysis DC has been associated with a 7.5-month delay in requiring dialysis commencement, having potential cost implications for health services. Limited studies have evaluated the possible impact of predialysis DC on health service costs. This study aimed to investigate the hospital health service costs associated for patients attending a predialysis dietetic clinic. A cost analysis comparing hospital health service costs over 4 years in a cohort of predialysis patients with and without DC. Retrospective study data were used (n = 246) along with outpatient renal clinic visits, hospital admissions records to estimate total hospital service costs. A generalized linear model evaluated associations between total cost and the marginal effects of DC and other variables on total costs. Mean total cost for patients (outpatient visits, admissions, and dialysis) was AUD$178,913 (95% confidence interval = $158,735-$199,090) or $185/day (95% confidence interval = $12-$161). The DC group total costs/day were lower than the no-DC group with a mean difference of $51/day ($155 vs. $206 P = .03). Patients in the DC group had less admissions compared to the no-DC group (6.32 vs. 8.06 P = .02). The highest marginal costs estimated for the entire cohort were lower estimated glomerular filtration rate at admission ($123,511, P = .001), inpatient admissions ($189,333, P < .001), commencing dialysis ($581,812, P < .001), having diabetes ($94,590, P = .014), and cerebrovascular disease ($177,080, P = .01). DC advice did not influence total costs. Patients who received DC had lower total health services costs/day compared to those who did not receive DC. Marginal cost analysis indicates the cost difference to be attributed to less time on dialysis and fewer hospital admissions in this retrospective observational cohort. An assessment of dietetic staffing in predialysis renal services is warranted.
Publisher: Springer Science and Business Media LLC
Date: 10-2020
Publisher: MDPI AG
Date: 21-10-2022
Abstract: Indigenous children and young people (hereafter youth) across CANZUS nations embody a rich ersity of cultures and traditions. Despite the immense challenges facing these youth, many harness cultural and personal strengths to protect and promote their wellbeing. To support this for all youth, it is critical to understand what contributes to their wellbeing. This review aims to identify components contributing to wellbeing for Indigenous youth in CANZUS nations. Five databases were searched from inception to August 2022. Papers were eligible if they: focused on Indigenous youth in CANZUS nations included views of youth or proxies and focused on at least one aspect of wellbeing. We identified 105 articles for inclusion (Canada n = 42, Australia n = 27, Aotearoa New Zealand n = 8, USA n = 28) and our analysis revealed a range of thematic areas within each nation that impact wellbeing for Indigenous youth. Findings highlight the unique challenges facing Indigenous youth, as well as their immense capacity to harness cultural and personal strengths to navigate into an uncertain future. The commonalities of Indigenous youth wellbeing across these nations provide valuable insights into how information and approaches can be shared across borders to the benefit of all Indigenous youth and future generations.
Publisher: Springer Science and Business Media LLC
Date: 10-06-2021
DOI: 10.1007/S40271-021-00529-9
Abstract: Given increasing patient populations, general practitioner workforce constraints and the growing demand for health services in New Zealand (NZ), the development and provision of pharmacist prescribing services could be used to improve people's access to medicines. A discrete choice experiment (DCE) was utilised to determine NZ public preferences for pharmacist prescribing services in primary care in NZ. A D-efficient DCE design generated 20 choice questions in four blocks of five questions with three labelled alternatives per choice question. The online DCE used a NZ general public online research panel administered by an external organisation (SurveyEngine). The DCE included six attributes with two attributes each with two levels (location of consultation and consultation type), three levels (type of service and operating hours) and four levels (waiting time and cost). Nine hundred and twenty-four respondents completed the survey with 4620 observations available for analyses. Respondents preferred pharmacist prescribing services with the following characteristics: optimisation of medicines and changes to only current medicine service types (relative to repeat prescribing) lower consultation costs, shorter waiting times, longer operating hours and consultation by appointment (relative to walk-in and wait clinic). Prescribing policy could incorporate these public preferences to help develop accessible and effective primary care prescribing services utilising the skills of pharmacist prescribers to improve and reduce inequities in access to medicines in NZ. These results suggest the NZ public see pharmacists as part of the primary care prescribing team and are willing to utilise them if these services are implemented.
Publisher: CSIRO Publishing
Date: 2012
DOI: 10.1071/SH12017
Abstract: Anal cancer is a relatively rare neoplasm, related to human papillomavirus (HPV), with an incidence that does not warrant general screening. However, as many cases occur in identifiable high-risk populations, targeting these groups may be cost-effective. Screening for anal cancer in men who have sex with men (MSM) may be appropriate, given their elevated risk of anal cancer. Examining existing cost-effectiveness analyses can help inform the design and conduct of future clinical and economic studies. A review of the literature was performed using three databases to identify studies that assessed the cost-effectiveness of anal cancer screening in MSM. Five analyses were identified: four modelled the cost-effectiveness of cytological screening over a patient’s lifetime, and estimated final health outcomes as survival or quality adjusted survival. The fifth presented a decision analysis with intermediate health outcomes only and did not extrapolate to longer-term health outcomes. Several factors influenced the incremental cost-effectiveness ratios. These factors were related to a paucity of primary data and included: availability of longer-term epidemiological and natural history data availability of utility-based quality of life data from an appropriate respondent population appropriate resource use information and availability of information on screening adherence. There is considerable uncertainty in model results: analyses from the United States suggest screening is almost always cost-effective analyses from the United Kingdom suggest that screening is unlikely to be cost-effective. Uncertainty is primarily driven by data paucity by summarising key uncertainties in existing models, this review can inform the design and conduct of future studies.
Publisher: Springer Science and Business Media LLC
Date: 20-02-2013
Publisher: Springer Science and Business Media LLC
Date: 15-08-2014
Publisher: Elsevier BV
Date: 02-2023
DOI: 10.1016/J.KINT.2022.09.026
Abstract: In this multi-center longitudinal cohort study conducted in Australia and New Zealand, we assessed the trajectories of health-related quality of life (HRQoL) in children with chronic kidney disease (CKD) over time. A total of 377 children (aged 6-18 years) with CKD stages 1-5 (pre-dialysis), dialysis, or transplant, were followed biennially for four years. Multi Attribute Utility (MAU) scores of HRQoL were measured at baseline and at two and four years using the McMaster Health Utilities Index Mark 3 tool, a generic multi-attribute, preference-based system. A multivariable linear mixed model was used to assess the trajectories of HRQoL over time in 199 children with CKD stage 1-5, 43 children receiving dialysis and 135 kidney transplant recipients. An interaction between CKD stage at baseline and follow-up time indicated that the slopes of the HRQoL scores differed between children by CKD stage at inception. Over half of the cohort on dialysis at baseline had received a kidney transplant by the end of year four and the MAU scores of these children increased by a meaningful amount averaging 0.05 (95% confidence interval 0.01 to 0.09) per year in comparison to those who were transplant recipients at baseline. The mean difference between baseline and year two MAU scores was 0.09 (95% confidence interval -0.05, 0.23), (Cohen's d effect size 0.31). Thus, improvement in HRQoL over time of children on dialysis at baseline was likely to have been driven by their transition from dialysis to transplantation. Additionally, children with CKD stage 1-5 and transplant recipients at baseline had no changes in their disease stage or treatment modality and experienced stable HRQoL over time.
Publisher: Springer Science and Business Media LLC
Date: 04-02-2019
DOI: 10.1007/S40258-018-00455-2
Abstract: The economic burden of providing maintenance dialysis to those with end-stage kidney disease continues to increase. Home dialysis, including both haemodialysis and peritoneal dialysis, is commonly assumed to be more cost effective than facility dialysis, with some countries adopting a home-first policy in an attempt to reduce costs. However, the cost effectiveness of this approach is uncertain. The aim of this study is to review all published cost-effectiveness analyses comparing all alternative dialysis modalities for people with end-stage kidney disease. We conducted a systematic review of MEDLINE, the National Health Service Economic Evaluation Database, and Health Technology Assessment Database from the Centre of Reviews and Dissemination, The Cochrane Library and Econlit from January 2000 to December 2017. Published economic evaluations were included if they provided comparative information on the costs and health outcomes of alternative dialysis modalities. The review identified 16 economic evaluations comparing dialysis modalities from both high- and low-income countries. The majority (69%) were undertaken solely from the perspective of the payer or service provider, 14 (88%) included a cost-utility analysis and eight (50%) were modelled evaluations. The studies addressed costs and health outcomes of multiple dialysis modalities, with many reporting average cost effectiveness rather than incremental cost effectiveness. Almost all evaluations suggest home dialysis to be less costly and to offer comparable or better health outcomes than in-centre haemodialysis. However, the quality-of-life benefit for each modality was poorly defined and inconsistent in terms of magnitude and direction of differences between modalities and across studies. Other issues include exclusion of competing modalities and use of arbitrary assumptions with regard to the mix of modalities. The ability to identify the mix of dialysis modalities that provides best outcomes for patients and health budgets is uncertain particularly given the lack of societal perspectives and inconsistencies between published studies.
Publisher: BMJ
Date: 10-01-2011
Abstract: Allocation decisions in emergency medicine must occur when demand for emergency services exceeds supply. In many circumstances, strong clinical or cost evidence upon which to base allocation decisions is lacking. In these circumstances, patient or community preference may be used to inform decisions. If preference is to be incorporated into allocation decision-making, scientifically rigorous quantitative methods should be chosen for measuring preference. This article describes the theoretical background, advantages, risks and applications of discrete choice experiments for measuring patient preference in emergency medicine.
Publisher: Springer Science and Business Media LLC
Date: 22-01-2009
Publisher: BMJ
Date: 05-2019
DOI: 10.1136/BMJGH-2019-001509
Abstract: A number of factors contribute to the performance and motivation of India’s Accredited Social Health Activists (ASHAs). This study aims to identify the key motivational factors (and their relative importance) that may help retain ASHAs in service. A discrete choice experiment (DCE) survey presented ASHAs with eight unlabelled choice sets, each describing two hypothetical jobs that varied based on five attributes, specifically salary, workload, travel allowance, supervision and other job benefits. Multinomial logit and latent class (LC) models were used to estimate stated preferences for the attributes. We invited 318 ASHAs from 53 primary health centres of Guntur, a district in south India. The DCE was completed by 299 ASHAs using Android tablets. ASHAs were found to exhibit a strong preference for jobs that incorporated training leading to promotion, a fixed salary and free family healthcare. ASHAs were willing to sacrifice 2530 Indian rupee (INR) from their monthly salary, for a job offering training leading to promotion opportunity and 879 INR for a free family health-check. However, there was significant heterogeneity in preferences across the respondents. The LC model identified three distinct groups (comprising 51%, 35% and 13% of our cohort, respectively). Group 1 and 2 preferences were dominated by the training and salary attributes with group 2 having higher preference for free family health-check while group 3 preferences were dominated by workload. Relative to group 3, ASHAs in groups 1 and 2 were more likely to have a higher level of education and less likely to be the main income earners for their families. ASHAs are motivated by both non-financial and financial factors and there is significant heterogeneity between workers. Policy decisions aimed at overcoming workforce attrition should target those areas that are most valued by ASHAs to maximise the value of investments into these workers. CTRI/2018/03/012425.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2016
Publisher: Springer Science and Business Media LLC
Date: 03-10-2023
Publisher: BMJ
Date: 2016
Publisher: Elsevier BV
Date: 04-2014
DOI: 10.1111/AJT.12660
Abstract: A major barrier to meeting the needs for organ transplantation is family refusal to give consent. This study aimed to describe the perspectives of donor families on deceased donation. We conducted a systematic review and thematic synthesis of qualitative studies. Electronic databases were searched to September 2012. From 34 studies involving 1035 participants, we identified seven themes: comprehension of sudden death (accepting finality of life, ambiguity of brain death) finding meaning in donation (altruism, letting the donor live on, fulfilling a moral obligation, easing grief) fear and suspicion (financial motivations, unwanted responsibility for death, medical mistrust) decisional conflict (pressured decision making, family consensus, internal dissonance, religious beliefs) vulnerability (valuing sensitivity and rapport, overwhelmed and disempowered) respecting the donor (honoring the donor's wishes, preserving body integrity) and needing closure (acknowledgment, regret over refusal, unresolved decisional uncertainty, feeling dismissed). Bereaved families report uncertainty about death and the donation process, emotional and cognitive burden and decisional dissonance, but can derive emotional benefit from the "lifesaving" act of donation. Strategies are needed to help families understand death in the context of donation, address anxieties about organ procurement, foster trust in the donation process, resolve insecurities in decision making and gain a sense of closure.
Publisher: Elsevier BV
Date: 05-2018
Publisher: BMJ
Date: 05-2020
DOI: 10.1136/BMJOPEN-2019-029265
Abstract: Solid organ transplant recipients are at increased risk of skin cancer, affecting more than 50% of recipients. We aimed to determine the effectiveness of interventions for behavioural change for sun protection or skin cancer prevention in solid organ transplant recipients. Systematic review. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) and CINAHL from inception to November 2019. We included randomised controlled trials that evaluated the effect of behavioural or pharmaceutical interventions on behavioural change or skin cancer prevention in solid organ transplant recipients. Risks of bias and evidence certainty were assessed using Cochrane and the Grading of Recommendations Assessment Development and Evaluation framework. Twenty trials (n=2295 participants) were included. It is uncertain whether behavioural interventions improve sun protection behaviour (n=3, n=414, standardised mean difference (SMD) 0.89, 95% CI −0.84 to 2.62, I 2 =98%) and knowledge (n=4, n=489, SMD 0.50, 95% CI 0.12 to 0.87, I 2= 76%) as the quality of evidence is very low. We are uncertain of the effects of mammalian target of rapamaycin inhibitors on the incidence of non-melanocytic skin cancer (n=5, n=1080, relative risk 0.46, 95% CI 0.28 to 0.75, I 2 = 72%) as the quality of evidence is very low. Behavioural and pharmaceutical preventive interventions may improve sun protective behaviour and knowledge, and reduce the incidence of non-melanocytic skin cancer, but the overall quality of the evidence is very low and insufficient to guide decision-making and clinical practice. CRD42017063962.
Publisher: Oxford University Press (OUP)
Date: 07-09-2016
DOI: 10.1093/NDT/GFV330
Abstract: Home dialysis can offer improved quality of life and economic benefits compared with facility dialysis. Yet the uptake of home dialysis remains low around the world, which may be partly due to patients' lack of knowledge and barriers to shared and informed decision-making. We aimed to describe patient and caregiver values, beliefs and experiences when considering home dialysis, to inform strategies to align policy and practice with patients' needs. Semi-structured interviews with adult patients with chronic kidney disease Stage 4-5D (on dialysis <1 year) and their caregivers, recruited from three nephrology centres in New Zealand. Transcripts were analysed thematically. In total, 43 patients [pre-dialysis (n = 18), peritoneal dialysis (n = 13), home haemodialysis (n = 4) and facility haemodialysis (n = 9)] and 9 caregivers participated. We identified five themes related to home dialysis: lacking decisional power (complexity of information, limited exposure to home dialysis, feeling disempowered, deprived of choice, pressure to choose), sustaining relationships (maintaining cultural involvement, family influence, trusting clinicians, minimizing social isolation), reducing lifestyle disruption (sustaining employment, avoiding relocation, considering additional expenses, seeking flexible schedules, creating free time), gaining confidence in choice (guarantee of safety, depending on professional certainty, reassurance from peers, overcoming fears) and maximizing survival. To engage and empower patients and caregivers to consider home dialysis, a stronger emphasis on the development of patient-focused educational programmes and resources is suggested. Pre-dialysis and home dialysis programmes that address health literacy and focus on cultural and social values may reduce fears and build confidence around decisions to undertake home dialysis. Financial burdens may be minimized through provision of reimbursement programmes, employment support and additional assistance for patients, particularly those residing in remote areas.
Publisher: Elsevier BV
Date: 07-2008
DOI: 10.1016/J.PEC.2008.01.024
Abstract: New human papillomavirus (HPV) DNA technologies for the detection and prevention of cervical cancer have led to exciting changes in cervical cancer screening worldwide. Their introduction, however, has left many women with unanswered medical and psychosocial HPV questions. This study considered the degree to which women's own HPV questions were addressed in Australian cervical cancer screening patient information leaflets. Based on previous qualitative research that asked women to identify their own HPV information needs, categories of interest were identified and a coding framework was developed. Manifest content analysis was conducted by counting the number of times a category of interest was stated in the text of the patient information leaflets (n=75). Latent content analysis methodology was employed to assess the underlying and embedded meaning within the leaflets. Women's medical questions were addressed more frequently than psychosocial ones. Leaflets were designed for specific target audiences (Aboriginal, lesbian, older women, women with disabilities, HPV-specific, cervical cancer-specific and general Pap screening) and the type and amount of HPV information varied by group. Merging the manifest and latent results, we identified three broad themes for discussion: the medicalisation of women's cervical screening experience, the purpose and target audience of cervical screening leaflets and HPV as a community versus women's health issue. Women's questions on HPV were inconsistently and often inadequately answered. In order that women's information needs are met, more accurate and balanced representations of medical and psychosocial HPV information should be provided in patient information leaflets.
Publisher: BMJ
Date: 08-2020
DOI: 10.1136/SEXTRANS-2019-054098
Abstract: Gay, bisexual and other men who have sex with men (GBMSM), particularly HIV-positive GBMSM, are at increased anal cancer risk compared with the general population. This study examined the psychological and quality of life (QoL) impact of receiving abnormal anal cancer screening results during the baseline visit of the Study of the Prevention of Anal Cancer (SPANC). SPANC was a prospective cohort study of the natural history of anal human papillomavirus (HPV) and associated abnormalities in GBM aged 35 years and over. Participants completed questionnaires including aspects of health-related QoL (HR-QoL) and psychosocial functioning at baseline. Participants underwent procedures including an anal swab for cytology, and high-resolution anoscopy with biopsy of any possibly HPV-related abnormality. Questionnaires were readministered 2 weeks and 3 months after participants were given cytology and histology results. Perceived test result served as the study factor. Participants with perceived abnormal results (n=232) reported poorer HR-QoL (mean difference=1.8 p=0.004) and lower utility-based QoL (mean difference=0.02 p=0.018) 2 weeks after screening than in iduals with perceived normal results (n=268). These differences did not persist at 3-month follow-up. A greater proportion of participants who perceived their results as abnormal reported feeling worse than usual about their anal health and anal cancer fear (p’s .001), experienced more intrusive thoughts about their results (p’s≤0.006) and felt more likely to develop cancer than other gay men their age (p’s≤0.025) at both time points than those with perceived normal results. Providing abnormal results may cause psychological distress and impact HR-QoL, with sustained intrusive thoughts, increased cancer worry and perceived cancer risk. The potential for psychological harm needs to be considered when implementing anal cancer screening programmes.
Publisher: Springer Science and Business Media LLC
Date: 18-04-2012
Publisher: Springer Science and Business Media LLC
Date: 26-02-2009
Publisher: Springer Science and Business Media LLC
Date: 24-01-2022
Publisher: Springer Science and Business Media LLC
Date: 29-10-2020
DOI: 10.1245/S10434-019-07963-Y
Abstract: Immunotherapy improves overall survival for patients with metatstatic melanoma and improves recurrence-free survival in the adjuvant setting, but is costly and has adverse effects. Little is known about the preferences of patients and clinicians regarding immunotherapy. This study aimed to identify factors important to patients and clinicians when deciding about immunotherapy for stages 2-4 melanoma. This study searched the Medline, EMBASE, ECONLIT, PsychINFO, and COCHRANE Systematic Reviews databases from inception to June 2018 for immunotherapy choice and preference studies. Findings were tabulated and summarized, and study reporting was assessed against recommended checklists. This investigation identified eight studies assessing preferences for melanoma treatment four studies regarding nivolumab, pembrolizumab, or ipilimumab and four studies regarding interferon conducted in the United States, Germany, and Australia. The following 10 factors were important to decision-making: overall survival, recurrence-free survival, treatment side effects, dosing regimen, patient or payer cost, patient age, clinician or family/friend treatment recommendation, quality of life, and psychosocial effects. Overall survival was the most important factor for all respondents. The patients judged severe toxicities to be tolerable for small survival gains. The description of information about treatment harms and benefits was limited in most studies. Overall survival was of primary importance to patients and clinicians considering immunotherapy. Impaired quality of life due to adverse effects appeared to be a second-order consideration. Future research is required to determine preferences for contemporary combination therapies, extended treatment durations, and avoidance of chronic side effects. PROSPERO registration number CRD42018095899.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 27-02-2008
Publisher: Oxford University Press (OUP)
Date: 22-02-2010
Abstract: emergency care for older people living in residential aged care facilities (RACF) is a complex area of health policy. The epidemiology of patient transfer between RACF and hospital emergency departments (ED), clinical outcomes and costs associated with transfer and efficacy of programs aiming to reduce transfer are not well known. systematic review based on a comprehensive literature search in three electronic databases and published article reference lists. the incidence of transfer from RACF to ED is >30 transfers/100 RACF beds/year in most studies. The casemix from RACF is varied and reflects that of the broad elderly population, with some risk difference. At least 40% of transfers are not admitted to hospital. There is insufficient data to fully address our other questions however, hospitalisations from RACF can be reduced through advanced care planning, use of management guidelines for acute illnesses and improved primary care. residents of RACF have a high annual risk of transfer to ED. The clinical benefit and cost effectiveness of ED care, and alternate programs to reduce ED transfer, cannot be confidently compared from published work. Further research is required to accurately describe these and to determine their comparative worth.
Publisher: Elsevier BV
Date: 05-2016
DOI: 10.1053/J.AJKD.2015.11.006
Abstract: Shared decision making regarding immunosuppression in kidney transplantation requires an understanding of effects on quality of life (QoL). Our aim was to review the frequency and reliability of QoL measures reported in randomized controlled trials of maintenance immunosuppression following kidney transplantation. Systematic literature review. Kidney transplant recipients enrolled in randomized trials of maintenance immunosuppression. Systematic search of the Cochrane Kidney and Transplant register, CENTRAL, MEDLINE, EMBASE, PsycINFO, and CINAHL databases to January 2014 identifying maintenance immunosuppression trials. An EQUATOR Network-endorsed checklist was used to assess QoL reporting and effect sizes estimated. Maintenance immunosuppression (comparative studies, dose adjustment, and agent withdrawal). Any quantitative patient-reported measure of physical, emotional, or social well-being. Of 2,272 reports, 41 (2% involving 4,549 participants from 23 trials) included QoL outcomes using 22 instruments (8 generic, 2 disease specific, and 12 symptom specific). Reporting was incomplete for the majority with 1 (4%) addressing all 11 items of the checklist, 4 (17%) addressing clinical significance, and 15 (65%) reporting outcomes selectively. Almost all (n = 96 [95%]) effect size estimates for 101 QoL outcomes (18 trials 3,919 participants) favored the interventions, with 37 (37%) statistically significant. In comparison, 30 (73%) clinical outcomes favored the intervention and 13 (31%) were significant. QoL outcomes are commonly secondary outcomes and may not be indexed or found using text word searches. Effect sizes were estimated from different QoL measures, populations, and interventions. The small number of trials limits the ability to identify statistically significant associations between effect size and study- atient-related factors. QoL is infrequently reported in immunosuppression trials in kidney transplantation, appears subject to major biases, and thus may be unreliable for decision making.
Publisher: Springer Science and Business Media LLC
Date: 24-02-2022
DOI: 10.1186/S12913-022-07628-9
Abstract: Aboriginal people in the Northern Territory (NT) suffer the heaviest burden of kidney failure in Australia with most living in remote areas at time of dialysis commencement. As there are few dialysis services in remote areas, many Aboriginal people are required to relocate often permanently, to access treatment. Missing dialysis treatments is not uncommon amongst Aboriginal patients but the relationship between location of dialysis service and dialysis attendance (and subsequent hospital use) has not been explored to date. To examine the relationships between location of dialysis service, dialysis attendance patterns and downstream health service use (overnight hospital admissions, emergency department presentations) among Aboriginal patients in the NT. Using linked hospital and dialysis registry datasets we analysed health service activity for 896 Aboriginal maintenance dialysis patients in the NT between 2008 and 2014. Multivariate linear regression and negative binomial regression analyses explored the associations between dialysis location, dialysis attendance and health service use. We found missing two or more dialysis treatments per month was more likely for Aboriginal people attending urban services and this was associated with a two-fold increase in the rate of hospital admissions and more than three-fold increase in ED presentations. However, we found higher dialysis attendance and lower health service utilisation for those receiving care in rural and remote settings. When adjusted for age, time on dialysis, region, comorbidities and residence pre-treatment, among Aboriginal people from remote areas, those dialysing in remote areas had lower rates of hospitalisations (IRR 0.56 P 0.001) when compared to those who relocated and dialysed in urban areas. There is a clear relationship between the provision and uptake of dialysis services in urban, rural and remote areas in the NT and subsequent broader health service utilisation. Our study suggests that the low dialysis attendance associated with relocation and care in urban models for Aboriginal people can potentially be ameliorated by access to rural and remote models and this warrants a rethinking of service delivery policy. If providers are to deliver effective and equitable services, the full range of intended and unintended consequences of a dialysis location should be incorporated into planning decisions.
Publisher: SAGE Publications
Date: 03-2019
Abstract: Peritoneal dialysis (PD) is a home-based therapy where nurses train patients in its use. There has been no published randomized controlled trial (RCT) evaluating any specific protocol for nurses delivering PD training. A standardized education package based upon the best available evidence and utilizing modern educational practices may lead to improved patient outcomes. The aim is to develop a standardized, evidence-based curriculum for PD trainers and patients aligned with guidelines from the International Society for Peritoneal Dialysis (ISPD), using best practice pedagogy. A literature search and clinical audit were conducted to identify current practice patterns and best practice. Results were reviewed by a focus group of practitioners comprising PD nurses, nephrologists, consumers, a medical education expert, and an eLearning expert. From this, a training curriculum and modules were developed. A comprehensive PD training curriculum has been developed, which includes modules for training PD nurses (trainers) and patient training manuals. The package comprises 2 introductory modules and 2 clinical case modules. The curriculum is designed for both interactive digital media (trainers) and traditional paper-based teaching with practical demonstrations (patients). Assessment is also addressed. The need for the development of a comprehensive and standardized curriculum for PD nurse trainers and their patients was confirmed. This paper outlines the process of the development of this curriculum. Pilot testing of the modules was launched in late 2017 to examine feasibility, and planning has commenced for a RCT in 2019 to investigate the effect of the modules on clinical outcomes, and their wider application across Australia and New Zealand.
Publisher: Oxford University Press (OUP)
Date: 06-09-2010
DOI: 10.1093/NDT/GFQ555
Abstract: Informed decision-making requires the presentation of all possible courses of action however, it is unclear what proportion of Stage 5 chronic kidney disease (CKD) patients are routinely informed of all their treatment options. The aim of this study was to determine the effect of patient and unit characteristics on the type and timing of information provided. A prospective national multi-centre study of information was given to incident pre-emptive transplant, dialysis and conservatively managed patients in Australian renal units, over a 3-month period. Sixty-six of 73 renal units participated in the study. Seven hundred and twenty-one incident CKD Stage 5 patients including 102 who chose not to dialyse were identified. Of these, 603 (84%) were presented with information about their options prior to commencing treatment. Three quarters (n = 543) were presented with home dialysis, one-third (n = 230) pre-emptive transplantation and 65% (n = 470) were informed about conservative care as an option. Patients were more likely to receive information prior to commencing treatment if they were known to a nephrologist for more than 3 months (OR 7.29, 95% CI 3.86-13.79) or were treated in small units with < 100 dialysis patients (OR 2.40, 95% CI 1.26-4.60). The mean estimated glomerular filtration rate at the time information was first presented was 13.3 mL/min/1.73 m(2) (95% CI 12.7-13.8) and mean serum creatinine was 449 μmol/L (95% CI 431-467). Most Australian patients were informed of their treatment options prior to starting treatment, albeit in late stage CKD. Earlier education and support for informed decision-making may help optimize the uptake of pre-emptive transplantation and home dialysis therapies.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 31-12-2014
Publisher: Springer Science and Business Media LLC
Date: 15-07-2020
DOI: 10.1186/S13063-020-4228-0
Abstract: We are performing a combined randomised and observational study comparing internal fixation to non-surgical management for common wrist fractures in older patients. This paper describes the statistical analysis plan. A Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly (CROSSFIRE) is a randomised controlled trial comparing two types of usual care for treating wrist fractures in older patients, surgical fixation using volar locking plates and non-surgical treatment using closed reduction and plaster immobilisation. The primary aim of this comparative-effectiveness study is to determine whether surgery is superior to non-surgical treatment with respect to patient-reported wrist function at 12 months post treatment. The secondary outcomes include radiographic outcomes, complication rates and patient-reported outcomes including quality of life, pain, treatment success and cosmesis. Primary analysis will use a two-s le t test and an intention-to-treat analysis using the randomised arm of the study. Statistical analyses will be two-tailed and significance will be determined by p 0.05. Sensitivity analyses will be conducted to assess for differences in intention-to-treat, per-protocol and as-treated analyses. Sensitivity analyses will also be conducted to assess selection bias by evaluating differences in participants between the randomised and observational study arms, and for bias relating to any missing data. An economic analysis will be conducted separately if surgery is shown to provide superior outcomes to a level of clinical significance. This statistical analysis plan describes the analysis of the CROSSFIRE study which aims to provide evidence to aid clinical decision-making in the treatment of distal radius fractures in older patients. CROSSFIRE was approved by The Hunter New England Human Research Ethics Committee (HNEHREC Reference No: 16/02/17/3.04). Registered on 22 July 2016 with The Australian and New Zealand Clinical Trials Registry (ANZCTR Number ACTRN12616000969460 ). This manuscript is based on v.11 of the statistical analysis plan. A copy of v.11, signed by the chief investigator and the senior statistician is kept at the administering institution.
Publisher: BMJ
Date: 2016
Publisher: Oxford University Press (OUP)
Date: 27-06-2016
Abstract: the smallest worthwhile effect (SWE) of an intervention is the smallest treatment effect that justifies the costs, risks and inconveniences associated with that health intervention. to estimate the SWE of exercise programs designed to prevent falls among older people and to compare estimates derived by two methodological approaches. discrete choice experiment (n = 220) and benefit-harm trade-off (subs le n = 66) methods were used. community-dwelling older people who reported a past fall or a mobility limitation answered online or face-to-face questionnaires. a substantial proportion of participants (82% in the discrete choice experiment and 50% in the benefit-harm trade-off study) did not consider that participation in the proposed exercise programs would be worthwhile, even if it reduced their risk of falling to 0%. Among remaining participants, the average SWE of participation in an exercise program was an absolute reduction in the risk of falling of 35% (standard deviation [SD] = 13) in the discrete choice experiment and 16% (SD = 11) in the benefit-harm trade-off study. many participants did not consider the hypothetical falls' risk reduction of the proposed exercise programs to be worth the associated costs and inconveniences. Greater community awareness of the fall prevention effects of exercise for older people is required.
Publisher: Elsevier BV
Date: 10-2011
DOI: 10.1016/J.JPEDS.2011.04.007
Abstract: To elicit utility-based quality of life (QOL) of adolescent kidney transplant recipients. We measured QOL in adolescent transplant recipients by using a visual analog scale (VAS), and 2 utility-based QOL measures, the Health Utilities Index (HUI) Mark 2/3 (HUI2/3), and the time trade-off. Participants aged 11-19 years old were recruited from 5 transplantation centers in Australia. Mean scores were compared by using paired t tests, and linear multiple regression was used to define predictors for time trade-off QOL weights. Twenty-six adolescents participated in the study. On a scale with extremes of 0 (death) and 1 (full health), the participants had a mean (SD) time trade-off QOL weight of 0.99 ± 0.01 and HUI2/3 utility scores of 0.86 ± 0.16 and 0.85 ± 0.21, respectively. Time trade-off values were significantly higher than HUI Mark 2 values (P = .01) and HUI Mark 3 values (P = .02). From the HUI measure, decrements were observed in specific QOL domains, including vision, emotion (depression and anxiety), cognition, and pain. Adolescent kidney transplant recipients had consistent and high values for their current QOL, which suggests that they perceive themselves to be close to full health. However, adequate emotional and cognitive support may improve their overall QOL.
Publisher: Springer Science and Business Media LLC
Date: 20-02-2019
DOI: 10.1007/S00467-019-04209-7
Abstract: To determine the association of socioeconomic disadvantage and parent-rated health in children with chronic kidney disease (CKD). A total of 377 children (aged 6-18 years) with CKD stages I-V (n = 199), on dialysis (n = 43), or with a kidney transplant (n = 135) were recruited from 2012 to 2016 in Australia and New Zealand. Associations of five socioeconomic status (SES) components and the global SES index with parent-rated health of the child were examined using adjusted logistic regression. The median age of participants was 12.6 years (interquartile range (IQR) 8.9-15.5). In the entire cohort, the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for poor parent-rated health were 1.85 (1.13-3.03) for lower household income, 1.78 (1.08-2.96) for families that did not own their own home, 2.50 (1.50-4.16) for caregivers who rated their financial status as poor, 0.84 (0.51-1.38) for lower educational attainment, and 1.68 (1.04-2.72) for children whose primary caregivers were unemployed. With reference to the highest global SES index quartile, adjusted ORs for poor parent-rated health in descending order were 1.49 (0.69-3.21), 2.11 (1.06-4.20), and 2.20 (1.09-4.46), respectively. The association between low SES and poor parent-rated health was modified by CKD stage, where lower global SES index was independently associated with poor parent-rated health in children with CKD stages I-V, but not children on dialysis or with kidney transplants (p = 0.04). Low SES is associated with poor parent-rated health in children with CKD stages I-V, but not children on dialysis and with kidney transplants.
Publisher: BMJ
Date: 05-2014
Publisher: Public Library of Science (PLoS)
Date: 24-02-2017
Publisher: SAGE Publications
Date: 21-11-2011
Abstract: (i) To document the current state of the English, Scottish, Welsh, Northern Irish and Australian bowel cancer screening programmes, according to seven key characteristics, and (ii) to explore the policy trade-offs resulting from inadequate funding. United Kingdom and Australia. A comparative case study design using document and key informant interview analysis. Data were collated for each national jurisdiction on seven key programme characteristics: screening frequency, population coverage, quality of test, programme model, quality of follow-up, quality of colonoscopy and quality of data collection. A list of optimal features for each of the seven characteristics was compiled, based on the FOBT screening literature and our detailed examination of each programme. Each country made different implementation choices or trade-offs intended to conserve costs and/or manage limited and expensive resources. The overall outcome of these trade-offs was probable lower programme effectiveness as a result of compromises such as reduced screening frequency, restricted target age range, the use of less accurate tests, the deliberate setting of low programme positivity rates or increased inconvenience to participants from re-testing. Insufficient funding has forced programme administrators to make trade-offs that may undermine the potential net population benefits achieved in randomized controlled trials. Such policy compromise contravenes the principle of evidence-based practice which is dependent on adequate funding being made available.
Publisher: Elsevier BV
Date: 05-2019
DOI: 10.1016/J.SOCSCIMED.2019.03.013
Abstract: There is increasing scientific consensus that a One Health approach (acknowledging links between human, animal and environmental health) is the most effective way of responding to emerging infectious disease (EID) threats. However, reviews of past EID events show that successful implementation of control strategies hinge on alignment with public values. Given the limited evidence about public values in this area, we sought to understand public preferences for attributes associated with One Health strategies for EID prevention and control, using a discrete choice experiment (DCE). The DCE was conducted in 2016 using an online panel of Australian respondents aged over 18. Participants were presented with 18 pairs of scenarios describing One Health strategies and outcomes, and asked to select their preferred one. Scenarios were described by nine attributes with varying levels: personal autonomy, economic development, environmental health, community cohesion, free trade and travel, zoonotic risk, mortality, animal welfare and food security. Respondents were broadly representative of the Australian population (n = 1999, mean age 45.3 years (range 18-89) 50.7% male). The public preferred scenarios in which in idual freedoms are not restricted for the greater good unemployment is low the environment is healthy there is good community cohesion travel, imports and exports are tightly controlled there is lower mortality and incidence of disease and where animal welfare and food security are protected. Although lower morbidity and mortality were preferable, respondents were willing to accept extra cases of severe disease and deaths to avoid reductions in some attributes. However, a mixed logit model indicated significant heterogeneity. A latent class analysis suggested wide variability across respondent classes in the valuation of attributes, and the trade-offs respondents were willing to accept. Therefore, a single approach to managing EID using One Health is unlikely to be acceptable to all community members.
Publisher: Springer Science and Business Media LLC
Date: 14-02-2022
Publisher: SAGE Publications
Date: 21-10-2020
Abstract: Peritoneal dialysis (PD) can offer more flexibility and independence compared with hemodialysis, yet uptake of PD remains low. Barriers to PD include the fear of dialyzing without medical assistance and uncertainty about recognizing and managing complications. There is increasing use of remote monitoring in automated peritoneal dialysis (APD), but little is known about its acceptability by patients and caregivers. We aimed to describe patients’ and caregivers’ expectations and experiences of remote monitoring for APD. Qualitative study design, using semi-structured face-to-face interviews of patients who either receiving PD or were considered eligible for PD, and their caregivers. Transcripts were analyzed using thematic analysis. Of the 34 participants, 27 were patients and the remainder caregivers. Four themes (with subthemes) were identified reducing patient burden (seeking reassurance and shared responsibility, convenience and accuracy) strengthening partnerships in care (empowering knowledge and understanding, increased accountability to dialysis team) improving access to treatment (saving time and money, providing timely care and avoiding hospital) and preserving quality patient–provider interactions (enhancing face-to-face contact, clarifying expectations of access and use of data). Remote monitoring may increase patient knowledge about their kidney disease and its treatment, encourage accountability to the clinical team, enhance partnerships with clinicians, and improve access to treatment and timely care. It is also important to ensure that remote monitoring does not replace face-to-face clinical contact with clinicians.
Publisher: Wiley
Date: 04-2015
DOI: 10.1111/HDI.12243
Abstract: Planning and funding a home hemodialysis (HD) program requires a well-organized effort and close collaboration between clinicians and administrators. This resource provides guidance on the processes that are involved, including a thorough situational analysis of the dialysis landscape, emphasizing the opportunity for a home HD program careful consideration of the clinical and operational characteristics of a proposed home HD program at your institution the development of a compelling business case, highlighting the clinical and organizational benefits of a home HD program and careful construction and evaluation of a request for proposal.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 15-04-2009
Publisher: Cambridge University Press (CUP)
Date: 2021
DOI: 10.1017/S0266462321000362
Abstract: A growing number of evaluation frameworks have emerged over recent years addressing the unique benefits and risk profiles of new classes of digital health technologies (DHTs). This systematic review aims to identify relevant frameworks and synthesize their recommendations into DHT-specific content to be considered when performing Health Technology Assessments (HTAs) for DHTs that manage chronic noncommunicable disease at home. Searches were undertaken of Medline, Embase, Econlit, CINAHL, and The Cochrane Library (January 2015 to March 2020), and relevant gray literature (January 2015 to August 2020) using keywords related to HTA, evaluation frameworks, and DHTs. Included framework reference lists were searched from 2010 until 2015. The EUNetHTA HTA Core Model version 3.0 was selected as a scaffold for content evaluation. Forty-four frameworks were identified, mainly covering clinical effectiveness ( n = 30) and safety ( n = 23) issues. DHT-specific content recommended by framework authors fell within 28 of the 145 HTA Core Model issues. A further twenty-two DHT-specific issues not currently in the HTA Core Model were recommended. Current HTA frameworks are unlikely to be sufficient for assessing DHTs. The development of DHT-specific content for HTA frameworks is h ered by DHTs having varied benefit and risk profiles. By focusing on DHTs that actively monitor/treat chronic noncommunicable diseases at home, we have extended DHT-specific content to all nine HTA Core Model domains. We plan to develop a supplementary evaluation framework for designing research studies, undertaking HTAs, and appraising the completeness of HTAs for DHTs.
Publisher: Wiley
Date: 23-07-2010
DOI: 10.1111/J.1440-1797.2010.01356.X
Abstract: Our previous article described the principles of conducting an economic evaluation for evidence-based medical decision making. This article provides some tips for reading, critically appraising and applying the findings of an economic evaluation in clinical practice.
Publisher: Elsevier BV
Date: 04-2018
DOI: 10.1016/J.JPHYS.2017.10.001
Abstract: Falling when older is a major public health issue. There is compelling evidence to show that specific exercise programs can reduce the risk and rate of falls in community-dwelling older people. Another major health issue for older people living in the community is upper limb dysfunction, including shoulder pain. Home-based exercise programs appeal to some older people, due to their convenience. This trial aims to determine the effectiveness and cost-effectiveness of a home-based lower limb exercise program compared with a home-based upper limb exercise program to prevent falls and upper limb dysfunction among community-dwelling people aged 65+ years. Randomised, controlled trial. A total of 576 community-dwelling people will be recruited from the Illawarra and Shoalhaven regions of New South Wales, Australia. Participants will be randomised to either a home-based lower limb exercise intervention or a home-based upper limb exercise intervention. The lower limb program is designed to improve balance and strength in the lower limbs. The upper limb program is designed to improve upper limb strength and mobility. Participants will attend three group-based instruction sessions to learn and progress the exercises, and will be instructed to perform the exercises three times per week at home for 12 months. The two primary outcomes will be fall rates, recorded with monthly calendars for a 12-month period, and upper limb dysfunction, measured with the Disability of the Arm, Shoulder and Hand questionnaire. Secondary outcomes will include: lower limb strength and balance shoulder strength and mobility physical activity quality of life attitudes to exercise proportion of fallers fear of falling and health and community service use. The cost-effectiveness of both exercise programs from a health and community service provider perspective will be evaluated. Negative binomial regression models will be used to estimate the between-group difference in fall rates. Modified Poisson regression models will be used to compare groups on dichotomous outcome measures. Linear regression models will be used to assess the effect of group allocation on the continuously scored measures, after adjusting for baseline scores. Two economic evaluations will be conducted: the first will assess cost-effectiveness of the lower limb program compared with the upper limb program and the second will assess cost-effectiveness of the upper limb program compared with the lower limb program. If effective, the trial will provide a model for both upper limb and lower limb exercise programs that can be performed at home and implemented at scale to community-dwelling older adults.
Publisher: Wiley
Date: 04-11-2016
Publisher: Springer Science and Business Media LLC
Date: 05-12-2010
Publisher: BMJ
Date: 05-2019
DOI: 10.1136/BMJOPEN-2018-023545
Abstract: Managing nutrition is critical for reducing morbidity and mortality in patients on haemodialysis but adherence to the complex dietary restrictions remains problematic. Innovative interventions to enhance the delivery of nutritional care are needed. The aim of this phase II trial is to evaluate the feasibility and effectiveness of a targeted mobile phone text messaging system to improve dietary and lifestyle behaviours in patients on long-term haemodialysis. Single-blinded randomised controlled trial with 6 months of follow-up in 130 patients on haemodialysis who will be randomised to either standard care or KIDNEYTEXT. The KIDNEYTEXT intervention group will receive three text messages per week for 6 months. The text messages provide customised dietary information and advice based on renal dietary guidelines and general healthy eating dietary guidelines, and motivation and support to improve behaviours. The primary outcome is feasibility including recruitment rate, drop-out rate, adherence to renal dietary recommendations, participant satisfaction and a process evaluation using semistructured interviews with a subset of purposively s led participants. Secondary and exploratory outcomes include a range of clinical and behavioural outcomes and a healthcare utilisation cost analysis will be undertaken. The study has been approved by the Western Sydney Local Health District Human Research Ethics Committee—Westmead. Results will be presented at scientific meetings and published in peer-reviewed publications. ACTRN12617001084370 Pre-results.
Publisher: Elsevier BV
Date: 12-2018
DOI: 10.1016/J.JPEDS.2018.07.030
Abstract: To examine the effect of age on associations between household income and overall health from birth to adolescence, and whether age patterns vary by country. It is uncertain whether income-related health inequalities remain stable, widen, or narrow as children age, which impacts optimal timing of equity-focused interventions. Systematic review (CRD42016038583) of MEDLINE, Embase, PsycINFO, CINAHL, SocINDEX (full-text), and EconLit (full-text) to April 2017. We included observational studies and trials in children and adolescents (0-18 years of age), examining age differences in associations between income and overall health (self-rated, clinician-rated, proxy-rated). One reviewer extracted data 2 evaluated risk of bias. Thirty-eight articles containing 43 studies (30 cross-sectional, 13 cohort) were identified, from high-income (n = 39) and middle-income (n = 4) countries. In the US (n = 21), positive income-health associations emerged in early childhood, and these inequalities typically widened progressively into adolescence. Relative to 0- to 3-year-olds, ratios of income-health coefficients ranged from 1.10-3.71 for 4-8 years of age, 1.26-3.86 for 9-12 years of age, 1.36-6.71 for 13-17 years. In the United Kingdom and Ireland (n = 8), inequalities emerged in early-to-mid childhood, but age patterns were less consistent. In other high-income countries (Australia, Canada, France, Germany, Japan, Republic of Korea), inequalities mostly persisted or widened with age. In middle-income countries, inequalities appeared to narrow (Indonesia n = 2) or persist (Brazil n = 2) with age. Limitations are unclear/high risk of bias and dataset overlap for some studies. In many countries, income-related health status inequalities persist or widen as children age. Interventions that improve health equity early in the life-course are needed.
Publisher: Elsevier BV
Date: 10-2020
Publisher: BMJ
Date: 08-03-2005
Publisher: MDPI AG
Date: 29-12-2022
Abstract: Little is known of the quality of life (QoL) of cancer patients in the Northern Territory (NT) of Australia, where healthcare delivery is geographically challenged. This exploratory study describes QoL among Aboriginal and non-Aboriginal cancer patients in the NT, in the first year of diagnosis. Participants were recruited from the only cancer care centre in the NT and completed the Assessment of Quality-of-Life questionnaire (AQoL-4D). The results were descriptively analysed. The participants’ (n = 63 mean age 58.8 years) mean AQoL utility score was 0.72 (SD 0.26) patients scored lowest in the relationships and mental health dimensions of the questionnaire (mean 0.89, SD 0.19, and 0.89, SD 0.17, respectively). Participants living in remote and very remote areas (46%) reported higher QoL scores, compared with participants in the outer regional capital city of the NT in the overall (mean 0.76, SD 0.22 and 0.78, SD 0.20 vs. 0.67, SD 0.29, respectively), and mental health dimensions (mean 0.92, SD 0.09 and mean 0.94, SD 0.06 vs. 0.85, SD 0.22, respectively). The findings were suggestive of clinically meaningful differences across socioeconomic groups, cancer and treatment types, and comorbidity status. Mean QoL scores were consistent with previous reports in other Australian cancer cohorts. The findings suggest a need to support cancer patients’ mental health and relationships during the diagnosis and treatment phase of their cancer journey.
Publisher: Wiley
Date: 15-11-2018
DOI: 10.1111/AJAG.12465
Abstract: To identify predictors and impact of adherence to a multifactorial fall-prevention program on falls and health service utilisation. Randomised controlled trial with a priori subgroup analysis within intervention group according to adherence. Participants were community dwelling, (≥65 years), not transported to hospital following fall-related paramedic care. The Attitudes to Falls-Related Interventions Scale (AFRIS) was completed at baseline, adherence levels were measured (three-point scale) at six months, and falls and health service utilisation were recorded for 12 months. Multivariate logistic regression and area under the curve were calculated with 95% confidence interval (CI). Attitudes to Falls-Related Interventions Scale scores (n = 85) were independent of baseline characteristics. At six months, 39 (46%) participants reported full adherence. Independent predictors of adherence were positive AFRIS (OR 4.10, 95% CI 1.48-11.39) and receiving 3+ recommendations (OR 3.36, 95% CI 1.26-9.00). Adherers experienced fewer falls (IRR 0.53, 95% CI 0.45-0.80) and fall-related health service use (emergency department presentations IRR 0.37, 95% CI 0.17-0.82) compared to non-adherers. Older adults who adhere to recommendations benefit, regardless of fall-risk profile.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2015
Publisher: Springer Science and Business Media LLC
Date: 19-05-2023
Publisher: Mary Ann Liebert Inc
Date: 10-2020
Publisher: Wiley
Date: 10-11-2015
DOI: 10.1111/HEX.12301
Publisher: American Medical Association (AMA)
Date: 22-10-2007
DOI: 10.1001/ARCHINTE.167.19.2039
Abstract: Many women who have participated in mammography screening are now approaching 70 years of age. These women are advised to consider both the benefits and harms of continuing to be screened. Doing so may be difficult for in idual women, and there are no evaluated decision support tools to assist them. To assess the effect of a decision aid (DA) about whether to continue or stop mammography screening for women aged 70 years, a population-based, randomized controlled trial was conducted in New South Wales, Australia. Women aged 70 years who had regularly participated in mammography screening were eligible to participate in the trial. Women received a DA providing balanced, quantitative information or standard information available from the screening program. The main outcomes were the percentage of women making an informed choice about whether to continue or stop screening and the percentage of women participating in the screening. Women who received the DA (the intervention group) were better informed than the control group (mean increase in knowledge score out of 10, 2.62 for the intervention group vs 0.68 for the control group P < .001), and a significantly greater percentage made an informed choice (73.5% vs 48.8% P < .001). The DA did not increase anxiety and slightly reduced decisional conflict. There was no difference in the percentage of women who participated in screening within 1 month. This DA increased knowledge and assisted women to make an informed choice. It did not alter participation in screening. The DA is an effective way to assist women to make a decision about continuing mammography screening and seems to be a feasible intervention within a population screening program.
Publisher: BMJ
Date: 2016
Publisher: Cambridge University Press (CUP)
Date: 2015
DOI: 10.1017/S0266462315000367
Abstract: Objectives: The aim of this study was to determine the role of community preference information from discrete choice studies of colorectal cancer (CRC) screening in health technology assessment (HTA) reports and subsequent policy decisions. Methods: We undertook a systematic review of discrete choice studies of CRC screening. Included studies were reviewed to assess the policy context of the research. For those studies that cited a recent or pending review of CRC screening, further searches were undertaken to determine the extent to which community preference information was incorporated into the HTA decision-making process. Results: Eight discrete choice studies that evaluated preferences for CRC screening were identified. Four of these studies referred to a national or local review of CRC screening in three countries: Australia, Canada, and the Netherlands. Our review of subsequently released health policy documents showed that while consideration was given to community views on CRC, policy was not informed by discrete choice evidence. Conclusions: Preferences and values of patients are increasingly being considered “evidence” to be incorporated into HTA reports. Discrete choice methodology is a rigorous quantitative method for eliciting preferences and while as a methodology it is growing in profile, it would appear that the results of such research are not being systematically translated or integrated into HTA reports. A formalized approach is needed to incorporate preference literature into the HTA decision-making process.
Publisher: SAGE Publications
Date: 07-2008
Abstract: No mixed methods research design blends typological and systemic approaches into a cohesive, multifaceted whole. A synergistic approach to mixed methods research uses the inherent strengths of both types of approaches, providing researchers with a comprehensive framework for making pivotal research design decisions. Grounded in both philosophy and practice, this approach enables researchers to identify what will be researched, how it will be researched, and why the research will be undertaken in their chosen way. Presented as a set of core principles and a conceptual framework, its practical application is illustrated through the authors' experience of mixing methods in a randomized controlled trial (RCT). The synergistic approach discussed in this article offers researchers an alternative mixed methods research approach.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2017
Publisher: Springer Science and Business Media LLC
Date: 25-05-2020
DOI: 10.1186/S13063-020-04359-2
Abstract: Delayed graft function, the requirement for dialysis due to poor kidney function post-transplant, is a frequent complication of deceased donor kidney transplantation and is associated with inferior outcomes and higher costs. Intravenous fluids given during and after transplantation may affect the risk of poor kidney function after transplant. The most commonly used fluid, isotonic sodium chloride (0.9% saline), contains a high chloride concentration, which may be associated with acute kidney injury, and could increase the risk of delayed graft function. Whether using a balanced, low-chloride fluid instead of 0.9% saline is safe and improves kidney function after deceased donor kidney transplantation is unknown. BEST-Fluids is an investigator-initiated, pragmatic, registry-based, multi-center, double-blind, randomized controlled trial. The primary objective is to compare the effect of intravenous Plasma-Lyte 148 (Plasmalyte), a balanced, low-chloride solution, with the effect of 0.9% saline on the incidence of delayed graft function in deceased donor kidney transplant recipients. From January 2018 onwards, 800 participants admitted for deceased donor kidney transplantation will be recruited over 3 years in Australia and New Zealand. Participants are randomized 1:1 to either intravenous Plasmalyte or 0.9% saline peri-operatively and until 48 h post-transplant, or until fluid is no longer required whichever comes first. Follow up is for 1 year. The primary outcome is the incidence of delayed graft function, defined as dialysis in the first 7 days post-transplant. Secondary outcomes include early kidney transplant function (composite of dialysis duration and rate of improvement in graft function when dialysis is not required), hyperkalemia, mortality, graft survival, graft function, quality of life, healthcare resource use, and cost-effectiveness. Participants are enrolled, randomized, and followed up using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. If using Plasmalyte instead of 0.9% saline is effective at reducing delayed graft function and improves other clinical outcomes in deceased donor kidney transplantation, this simple, inexpensive change to using a balanced low-chloride intravenous fluid at the time of transplantation could be easily implemented in the vast majority of transplant settings worldwide. Australian New Zealand Clinical Trials Registry: ACTRN12617000358347 . Registered on 8 March 2017. ClinicalTrials.gov: NCT03829488 . Registered on 4 February 2019.
Publisher: Springer Science and Business Media LLC
Date: 09-10-2013
Publisher: Elsevier BV
Date: 12-2007
Publisher: Elsevier BV
Date: 10-2013
DOI: 10.1016/J.JPEDS.2013.04.066
Abstract: To elicit utility-based quality of life (QOL) in adolescents and young adults with chronic kidney disease (CKD). A cross-sectional study was conducted among patients aged 12-25 years with CKD stage 3-5 and 5D from 6 centers in Australia. QOL was measured using a visual analogue scale, and 3 utility-based QOL measures: Health Utilities Index Mark 2 and 3 (HUI2/3), Kidney Disease Quality of Life, incorporating the short form (SF)-12 transformed to SF-6D, and time trade-off (TTO). Multiple linear regression was used to define predictors for TTO QOL weights, SF-6D, and visual analogue scale scores. On a utility scale, with extremes of 0 (death) to 1 (full health), the 27 participants had a mean TTO QOL weight of 0.59 (SD = 0.40), HUI2 of 0.73 (SD = 0.28), HUI3 of 0.74 (SD = 0.26), and SF-6D of 0.70 (SD = 0.14). QOL weights were consistently low across the 4 utility-based instruments with widest variability in TTO responses. Mean QOL weights were higher among predialysis participants. The HUI2 indicated variability in the domain of emotion. From the Kidney Disease Quality of Life measures, decrements were observed in all QOL domains though dialysis patients reported a significantly higher burden attributed to kidney disease. Adolescent and young adults with CKD report low QOL values. Their utility-based QOL scores imply they are willing to trade considerable life expectancy for perfect health. Holistic care to improve QOL and minimize disease burden are imperative for optimizing health outcomes in young people with CKD, particularly those on dialysis.
Publisher: Elsevier BV
Date: 07-2021
DOI: 10.1053/J.AJKD.2020.11.015
Abstract: An important component of hemodialysis management involves delivery of complex dietary recommendations. The aim of this study was to determine the feasibility of a mobile phone text-message intervention to improve dietary behavior in people undergoing hemodialysis. Six-month randomized feasibility study. Patients receiving maintenance hemodialysis across 2 health districts in Sydney, Australia. Participants randomized to the intervention received 3 text messages per week in addition to standard dietary care for 6 months. The usual care group received standard dietary care. The primary outcomes were feasibility measured using recruitment and retention rates, acceptability of the intervention, and adherence to dietary recommendations. Secondary exploratory outcomes included information on certain clinical parameters related to dietary management of patients receiving maintenance hemodialysis. 130 people were recruited 48% of eligible patients (130 of 272) consented to participate, and 88% (115 of 130) completed the study. Semistructured interviews evaluating acceptability identified 5 themes: clear and comprehensive, engaging with consistent and relevant content, maintaining attention with timely reminders, sustaining interest through ongoing care, and generic messages inadequate to prompt dietary change. There was no difference in adherence to dietary recommendations across treatment groups (odds ratio, 1.21 [95% CI, 0.55-2.72] P = 0.6). Secondary exploratory analyses suggested reductions in dietary intake of single nutrients (potassium, phosphorus, sodium, protein), interdialytic weight gain, and phosphate binder use among intervention participants compared with participants assigned to standard care. Our feasibility study was of short duration. Adherence was based on self-reported data. Generalizability to populations receiving maintenance hemodialysis outside of an urban, Australian setting is unknown. A simple mobile phone text-messaging intervention was feasible and acceptable to patients. Further investigation of the impact on patient-reported and clinical outcomes is warranted. Funding for the study was provided by a Sydney Medical School Foundation Grant and the Centre for Transplant and Renal Research at Westmead Hospital. Registered at Australian New Zealand Clinical Trials Registry with study number ACTRN12617001084370.
Publisher: MDPI AG
Date: 21-07-2021
Abstract: Wellbeing is culturally bound and is shaped by many aspects of life, including experiences, beliefs and values. As such, in order to accurately measure wellbeing for a specific cultural group, it is necessary to understand the experiences, beliefs and values that influence the conception and experience of wellbeing of that group. This paper presents a conceptual model of wellbeing for Aboriginal and Torres Strait Islander people, which was developed from a large national qualitative study that explored the views of 359 Aboriginal and Torres Strait Islander adults. An Aboriginal- and Torres Strait Islander-led research team used an Indigenist research approach to iteratively develop this conceptual model, called the Fabric of Aboriginal and Torres Strait Islander Wellbeing model, which takes inspiration from Aboriginal and Torres Strait Islander weaving traditions whereby in idual strands are twined to create fabrics that are both beautiful and strong. This reflects our findings that the parts of life that are most important to wellbeing for many Aboriginal and Torres Strait Islander people are interwoven with their families, communities and culture.
Publisher: Wiley
Date: 20-02-2018
DOI: 10.1111/NEP.12992
Abstract: Up to a 10-fold difference in clinical outcomes between Australian peritoneal dialysis (PD) units exists. There is an international focus on the harmonization of educational practices in PD to determine whether this may lead to improved patient outcomes. The aim of this paper is to evaluate the current teaching practices of nurses and patients in Australian PD units. An online survey with questions on nurse and patient training was made available to PD units in Australia. Thirty-eight (70%) of 54 PD units in Australia completed the survey. A written standardized curricula was utilized in 21 units (55%) for nursing staff and 30 units (79%) for patients, with 23% and 12% including an electronic delivery component for each group, respectively. Universal teaching of adult learning principles was not demonstrated. The hours spent on teaching nursing staff ranged from 100 h in 21% of units. The average number of hours spent by nurses each day to train patients ranged from 6 h in 11% of units, with the average total training days ranging from 2 to 3 days in 14% to over 7 days in 14% of units. Staff and patient competency assessments were performed routinely in 37% and 74% of units, respectively. Considerable differences exist amongst Australian PD units in the education of staff and patients. There is a general lack of delivery and competency assessment to meet educational standards. It remains to be seen if harmonization of educational curricula can translate to improved clinical outcomes.
Publisher: American Medical Association (AMA)
Date: 10-2018
Publisher: Cambridge University Press (CUP)
Date: 20-12-2021
DOI: 10.1017/S0266462321001665
Abstract: As health services increasingly make investment decisions in digital health technologies (DHTs), a DHT-specific and comprehensive health technology assessment (HTA) process is crucial in assessing value-for-money. Research in DHTs is ever-increasing, but whether it covers the content required for HTA is unknown. To summarize current trends in primary research on DHTs that manage chronic disease at home, particularly the coverage of content recommended for DHT-specific and comprehensive HTA. Medline, Embase, Econlit, CINAHL, and The Cochrane Library (1 January 2015 to 20 March 2020) were searched for primary research studies using keywords related to DHT and HTA domains. Studies were assessed for coverage of the most frequently recommended content to be considered in a nine domain DHT-specific HTA previously developed. A total of 178 DHT interventions were identified, predominantly randomized controlled trials targeting cardiovascular disease/diabetes in high- to middle-income countries. A coverage assessment of the cardiovascular and diabetes DHT studies (112) revealed less than half covered DHT-specific content in all but the health problem domain. Content common to all technologies but essential for DHTs was covered by more than half the studies in all domains except for the effectiveness and ethical analysis domains. Although DHT research is increasing, it is not covering all the content recommended for a DHT-specific and comprehensive HTA. The inability to conduct such an HTA may lead to health services making suboptimal investment decisions. Measures to increase the quality of trial design and reporting are required in DHT primary research.
Publisher: Wiley
Date: 2012
DOI: 10.1111/J.1445-5994.2010.02224.X
Abstract: In order to design optimal systems to meet the acute healthcare needs of the frail elderly living in residential care, good clinical information is essential. The aims of this study were to analyse the casemix and outcomes of patients transferred from residential aged care facilities to public hospital emergency departments in New South Wales. In idual patient data from six hospital emergency departments and inpatient wards were obtained from merged databases and analysed using descriptive and comparative statistics. Outcomes in 4680 patient transfers over a 12-month period in 2006-2007 were analysed. Transfers occur mostly in high-acuity patients, with approximately three of every four transfers admitted one in every 12 dying and admitted patients undergoing an average of 2.4 interventions or procedures during each hospital stay. Several variables are associated with prolonged length of emergency department stay including triage urgency, type of hospital and transfers occurring in winter or out of hours. Patients transferred from aged care facilities to emergency departments are predominantly high-acuity patients with a substantial likelihood of hospitalisation, intervention and death. Nevertheless, scope exists for some episodes of acute care, in both discharged and admitted patients, to be provided outside a hospital setting.
Publisher: Oxford University Press (OUP)
Date: 18-12-2014
Abstract: despite evidence on what works in falls prevention, falls in older people remain an important public health problem. the purpose of this study was to model the impact and cost-effectiveness of a public health falls prevention programme, from the perspective of the health funder. a decision analytic Markov model compared the health benefits in quality-adjusted life years (QALYs) and costs of treatment and residential aged care with and without a population heath falls prevention programme. Different intervention costs, uptake levels and programme effectiveness were modelled in sensitivity analyses. Uncertainty was explored using univariate and probabilistic sensitivity analysis. widespread rollout of a public health fall prevention programme could result in an incremental cost-effectiveness ratio (ICER) of $A28,931 per QALY gained, assuming a programme cost of $700 per person and at a fall prevention risk ratio of 0.75. This ICER would be considered cost-effective at a threshold value of $A50,000 per QALY gained. Sensitivity analyses for programme cost and effectiveness indicated that the public health programme produced greater health outcomes and was less costly than no programme when programme costs were $A500 or lower and risk ratio for falls was 0.70 or lower. At a cost of $A2,500, the public health falls prevention programme ceases to be a cost-effective option. serious consideration should be given to implementation of a public health programme of falls prevention as a cost-effective option that enables population-wide access to the intervention strategies.
Publisher: Springer Science and Business Media LLC
Date: 26-08-2011
Publisher: Springer Science and Business Media LLC
Date: 18-04-2019
DOI: 10.1186/S12882-019-1325-Y
Abstract: Chronic kidney disease (CKD) is a devastating illness associated with increased mortality, reduced quality of life, impaired growth, neurocognitive impairment and psychosocial maladjustment in children. There is growing evidence of socioeconomic disparities in health outcomes among children with CKD. Patient navigators are trained non-medical personnel who assist patients with chronic conditions journey through the continuum of care and transit across different care settings. They help vulnerable and underserved populations to better understand their diagnosis, treatment options, and available resources, guide them through complex medical systems, and help them to overcome barriers to health care access. Given the complexity and chronicity of the disease process and concerns that current models of care may not adequately support the provision of high-level care in children with CKD from socioeconomically disadvantaged backgrounds, a patient navigator program may improve the provision of care and overall health of children with CKD. The NAV-KIDS 2 trial is a multi-centre, staggered entry, waitlisted randomised controlled trial assessing the health benefits and costs of a patient navigator program in children with CKD (stages 3–5, on dialysis, and with kidney transplants), who are of low socioeconomic backgrounds. Across 5 sites, 210 patients aged from 3 to 17 years will be randomised to immediate receipt of a patient navigator intervention for 24 weeks or waitlisting with standard care until receipt of a patient navigator at 24 weeks. The primary outcome is child self-rated health (SRH) 6-months after completion of the intervention. Other outcomes include utility-based quality of life, caregiver SRH, satisfaction with healthcare, progression of kidney dysfunction, other biomarkers, missed school days, hospitalisations and mortality. The trial also includes an economic evaluation and process evaluation, which will assess the cost-effectiveness, fidelity and barriers and enablers of implementing a patient navigator program in this setting. This study will provide clear evidence on the effectiveness and cost-effectiveness of a new intervention aiming to improve overall health and well-being for children with CKD from socioeconomically disadvantaged backgrounds, through a high quality, well-powered clinical trial. Prospectively registered (12/07/2018) on the Australian New Zealand Clinical Trials Registry ( ACTRN12618001152213 ).
Publisher: BMJ
Date: 10-2015
Publisher: Public Library of Science (PLoS)
Date: 22-07-2021
DOI: 10.1371/JOURNAL.PONE.0254575
Abstract: Working in partnership with Indigenous communities in South Australia, we aimed to develop, pilot test and estimate utility scores for health states relating to cervical cancer screening, precancer, and invasive cervical cancer and precancer/cancer treatment among Indigenous women. Development and pilot testing of hypothetical cervical cancer health states, specifically through the lens of being an Indigenous Australian woman, was done with an Indigenous Reference Group in conjunction with five female Indigenous community members. Six health states were developed. These included: (1) Screened: cytology normal (2) human papillomaviruses (HPV) positive with cytology normal (3) low grade cytology (LSIL) (4) high grade cytology (HSIL) (5) early stage cervical cancer and (6) later stage cervical cancer. Utility scores were calculated using a two-stage standard gamble approach among a large cohort of Indigenous Australian women taking part in a broader study involving oral HPV infection. The mean and standard deviation (SD) of the rank, percentage of respondents with a utility = 1 (perfect health) and utility score of each health state was summarised. Mean (SD) and medians and inter-quartile range (IQR) over 12 months and lifetime duration were calculated. Potential differences by age and residential location were assessed using the Wilcox Sum Rank test. Data was obtained from 513 Indigenous women aged 19+ years. Mean utility scores were higher for the four non-cancer health states than for invasive cervical cancer states (p-values .05). Lower mean utility scores were observed for late stage cervical cancer, with 0.69 at 12 months and 0.70 for lifetime duration (Intra-class correlation coefficients = 0.425). Higher utility scores were observed for the four non-cancer health states among non-metropolitan participants (ranged from 0.93 to 0.98) compared with metropolitan participants (ranged from 0.86 to 0.93) (p-values .05). Among a large cohort of Indigenous Australian women, the reduction in quality of life (which utilities reflect) was perceived to be greater with increasing severity of cervical cancer health states. There were differences observed by geographic location, with positive cervical screening and precursor cancer-related quality of life being much higher among non-metropolitan-dwelling participants. These utility values, from one of the largest such studies ever performed in any population will be uniquely able to inform modelled evaluations of the benefits and costs of cervical cancer prevention interventions in Indigenous women.
Publisher: Wiley
Date: 31-01-2019
Publisher: Elsevier BV
Date: 06-2015
DOI: 10.1016/J.JAMDA.2015.01.075
Abstract: Older people who have been recently discharged from hospital are at increased risk of falls and deterioration in physical functioning. To investigate the cost-effectiveness of a 12-month home-exercise program for older adults after hospitalization. An economic evaluation was conducted alongside a randomized controlled trial. The analysis was conducted from the health and community service provider perspective. A total of 340 people aged 60 years and older, with a recent hospital admission, were randomized into exercise and usual care control groups. Incremental costs per extra person showing improvement in mobility performance (using the Short Physical Performance Battery), per person indicating improvement in health (self-reported using a 3-point Likert scale) and per quality-adjusted life year (QALY) gained (utility measured using the EQ-5D) were estimated. Uncertainty was represented using cost-effectiveness acceptability curves. Subgroup analyses for participants with better cognition (above the median MMSE score of 28) also were undertaken. The average cost of the intervention was $A751 per participant. The incremental cost-effectiveness of the program relative to usual care was $A22,958 per extra person showing an improvement in mobility, $A19,020 per extra person indicating an improvement in health, and $A77,403 per QALY. The acceptability curve demonstrates that the intervention had an 80% probability of being cost-effective relative to the control at a threshold of $A48,000 per extra person achieving mobility improvement and $A36,000 indicating an improvement in self-reported health. There was no threshold value at which the program can be considered as having an 80% probability of cost-effectiveness for the QALY outcome. Subgroup analyses for participants with better cognitive status indicated improved cost-effectiveness for all outcomes. The exercise intervention appeared to offer reasonable value for money for mobility outcomes and self-reported health status. Value for money for all measures was greater in the higher cognitive status subgroup.
Publisher: Springer Science and Business Media LLC
Date: 27-09-2017
DOI: 10.1038/IJO.2016.165
Abstract: Modelling is increasingly being used to predict the epidemiology of obesity progression and its consequences. The aims of this study were: (a) to present and validate a model for prediction of obesity among Australian adults and (b) to use the model to project the prevalence of obesity and severe obesity by 2025. In idual level simulation combined with survey estimation techniques to model changing population body mass index (BMI) distribution over time. The model input population was derived from a nationally representative survey in 1995, representing over 12 million adults. Simulations were run for 30 years. The model was validated retrospectively and then used to predict obesity and severe obesity by 2025 among different aged cohorts and at a whole population level. The changing BMI distribution over time was well predicted by the model and projected prevalence of weight status groups agreed with population level data in 2008, 2012 and 2014.The model predicts more growth in obesity among younger than older adult cohorts. Projections at a whole population level, were that healthy weight will decline, overweight will remain steady, but obesity and severe obesity prevalence will continue to increase beyond 2016. Adult obesity prevalence was projected to increase from 19% in 1995 to 35% by 2025. Severe obesity (BMI>35), which was only around 5% in 1995, was projected to be 13% by 2025, two to three times the 1995 levels. The projected rise in obesity severe obesity will have more substantial cost and healthcare system implications than in previous decades. Having a robust epidemiological model is key to predicting these long-term costs and health outcomes into the future.
Publisher: Wiley
Date: 08-06-2022
DOI: 10.1111/HEX.13508
Abstract: The preferences of autism stakeholders regarding the top priorities for future autism research are largely unknown. This study had two objectives: First, to examine what autism stakeholders think new research investments should be and the attributes of investment that they consider important, and second, to explore the feasibility, acceptability and outcomes of two prioritization exercises among autism stakeholders regarding their priorities for future research in autism. This was a prospective stakeholder‐engaged iterative study consisting of best–worst scaling (BWS) and direct prioritization exercise. A national snowball s le of 219 stakeholders was included: adults with autism, caregivers, service providers and researchers. The main outcomes measures were attributes that participants value in future research investments, and priority research investments for future research. Two hundred and nineteen participants completed the exercises, of whom 11% were adults with autism, 58% were parents/family members, 37% were service providers and 21% were researchers. Among stakeholders, the BWS exercises were easier to understand than the direct prioritization, less frequently skipped and yielded more consistent results. The proportion of children with autism affected by the research was the most important attribute for all types of stakeholders. The top three priorities among future research investments were (1) evidence on which child, family and intervention characteristics lead to the best/worst outcomes (2) evidence on how changes in one area of a child's life are related to changes in other areas and (3) evidence on dietary interventions. Priorities were similar for all stakeholder types. The values and priorities examined here provide a road map for investigators and funders to pursue autism research that matters to stakeholders. Stakeholders completed a BWS and direct prioritization exercise to inform us about their priorities for future autism research.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-11-2022
Publisher: BMJ
Date: 06-2016
Publisher: Elsevier BV
Date: 07-2018
DOI: 10.1053/J.AJKD.2017.11.010
Abstract: Clinical trials are most informative for evidence-based decision making when they consistently measure and report outcomes of relevance to stakeholders. We aimed to assess the scope and consistency of outcomes reported in trials for hemodialysis. Systematic review. Adults requiring maintenance hemodialysis enrolled in clinical trials. All Cochrane systematic reviews of interventions published by August 29, 2016, and the trials published and registered in ClinicalTrials.gov since January 2011. Any hemodialysis-related interventions. Frequency and characteristics of the reported outcome domains and measures. From the 362 trials, we extracted and classified 10,713 outcome measures (a median of 21 [IQR, 10-39] per trial) into 81 different outcome domains, of which 42 (52%) were surrogate 25 (31%), clinical and 14 (17%), patient reported. The number of outcome measures reported significantly changed over time. The 5 most commonly reported domains were all surrogates: phosphate (125 [35%] trials), dialysis adequacy (120 [33%]), anemia (115 [32%]), inflammatory markers (114 [31%]), and calcium (109 [30%]). Mortality, cardiovascular diseases, and quality of life were reported very infrequently (73 [20%], 44 [12%], and 32 [9%], respectively). For feasibility, we included a s ling frame that included only trials identified in Cochrane systematic reviews or ClinicalTrials.gov. Outcomes reported in clinical trials involving adults receiving hemodialysis are focused on surrogate outcomes, rather than clinical and patient-centered outcomes. There is also extreme multiplicity and heterogeneity at every level: domain, measure, metric, and time point. Estimates of the comparative effectiveness of available interventions are unreliable and improvements over time have been inconsistent.
Publisher: Elsevier BV
Date: 07-2018
DOI: 10.1016/J.ARCHGER.2018.05.001
Abstract: Optimising quality of life and reducing hospitalisation for people living in residential aged care facilities (RACF) are important health policy goals. A cluster controlled clinical trial of nurse practitioner care in RACF. Six facilities were included: three randomly allocated to intervention where nurse practitioners working with general practitioners and using a best practice guide were responsible for care, and three control. Participants were followed up for a minimum of 12 months unless dead or transferred to another facility. We enrolled two hundred patients (101 intervention and 99 control) with a mean (SD) follow up of 604 (276) days. There were 98 ED visits by intervention participants, resulting in 56 hospitalisations, compared with 121 ED visits and 70 hospitalisations for controls (risk reduction = 8%, 95% CI = -1% -17%, p = 0.10). For the pre-specified secondary outcomes of transfers within the first 12 months of enrolment, the number of residents making at least one visit (46 in each study arm) and rate of ED attendance (0.66 visits per intervention resident versus 0.70 visits per control resident) was not affected by the intervention. After adjusting for dependency and comorbidity, the intervention group had non-significantly lower transfers (OR 0.7, 95% CI 0.3-1.5, p = 0.34). There was a reduction in the rate of decline in the quality of life of intervention compared to control residents. Nurse practitioner care coordination resulted in no statistically significant change in rates of ED transfer or health care utilisation, but better maintained resident quality of life.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2015
DOI: 10.1161/CIRCOUTCOMES.115.001483
Abstract: This study explores health provider and patient attitudes toward the use of a cardiovascular polypill as a health service strategy to improve cardiovascular prevention. In-depth, semistructured interviews (n=94) were conducted with health providers and patients from Australian general practice, Aboriginal community-controlled and government-run Indigenous Health Services participating in a pragmatic randomized controlled trial evaluating a polypill-based strategy for high-risk primary and secondary cardiovascular disease prevention. Interview topics included polypill strategy acceptability, factors affecting adherence, and trial implementation. Transcribed interview data were analyzed thematically and interpretively. Polypill patients commented frequently on cost-savings, ease, and convenience of a daily-dosing pill. Most providers considered a polypill strategy to facilitate improved patient medication use. Indigenous Health Services providers and indigenous patients thought the strategy acceptable and beneficial for indigenous patients given the high disease burden. Providers noted the inflexibility of the fixed dose regimen, with dosages sometimes inappropriate for patients with complex management considerations. Future polypill formulations with varied strengths and classes of medications may overcome this barrier. Many providers suggested the polypill strategy, in its current formulations, might be more suited to high-risk primary prevention patients. The polypill strategy was generally acceptable to patients and providers in cardiovascular prevention. Limitations to provider acceptability of this particular polypill were revealed, as was a perception it might be more suitable for high-risk primary prevention patients, though future combinations could facilitate its use in secondary prevention. Participants suggested a polypill-based strategy as particularly appropriate for lowering the high cardiovascular burden in indigenous populations. URL: www.anzctr.org.au . ANZCTRN: 12608000583347.
Publisher: Public Library of Science (PLoS)
Date: 18-02-2020
Publisher: Oxford University Press (OUP)
Date: 21-02-2012
DOI: 10.1093/NDT/GFS022
Abstract: Diabetes and chronic kidney disease (CKD) are both associated with an increased risk of cancer but it is unclear whether diabetes complicated by CKD further augments an in idual's cancer risk. The aim of our study was to determine the association of CKD [defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min] with the overall and site-specific risks of incident cancers among in iduals with Type 2 diabetes. Cox proportional hazard regression models and competing risk analyses were used to examine the univariate and multivariate adjusted associations between reduced kidney function and the overall and site-specific risks of cancer in participants enrolled in the Action in Diabetes and Vascular disease: Preterax and Diamicron MR controlled evaluation (ADVANCE) trial. Over a median follow-up of 5.0 years, 700 malignant neoplasms occurred in the 11 140 (6.4%) participants. There was no increase in overall cancer risk [adjusted hazard ratio: 1.07 (95% confidence interval: 0.89-1.29, P = 0.50)] or site-specific cancer risk for in iduals with CKD (defined as eGFR < 60 mL/min) compared to those without CKD at baseline. These results were robust to multiple methods and thresholds used to estimate CKD. Mild to moderate CKD does not increase the risk of cancer in people with Type 2 diabetes. ADVANCE is registered with ClincalTrial.gov (number NCT00145925).
Publisher: Wiley
Date: 26-12-2015
DOI: 10.1111/AJAG.12125
Abstract: To explore perspectives of three groups concerning transfers from aged care facilities to emergency departments. We sought to reveal factors influencing transfer decisions how active each group was in making decisions and to what extent groups ceded decision-making to others. Semi-structured interviews of 11 residents, 14 relatives and 17 staff with content analysis of interview transcripts. The three groups substantially differed in their involvement with initiating, and attitudes towards, transfer. Residents were least likely to be involved in the decision, yet most likely to support transfer. Staff felt conflicted between their desire to provide optimal treatment for one ill resident, and their obligations to other residents under care. Staff perspectives were largely consistent with published data, but we describe new results for other informant groups. Group expectations and preferences differ substantially. Service delivery to meet all preferences presents a challenge for health service design.
Publisher: Springer Science and Business Media LLC
Date: 12-2012
Abstract: The National Cervical Screening Program in Australia currently recommends that women aged 18–69 years are screened with conventional cytology every 2 years. Publicly funded HPV vaccination was introduced in 2007, and partly as a consequence, a renewal of the screening program that includes a review of screening recommendations has recently been announced. This study aimed to provide a baseline for such a review by quantifying screening program resource utilisation and costs in 2010. A detailed model of current cervical screening practice in Australia was constructed and we used data from the Victorian Cervical Cytology Registry to model age-specific compliance with screening and follow-up. We applied model-derived rate estimates to the 2010 Australian female population to calculate costs and numbers of colposcopies, biopsies, treatments for precancer and cervical cancers in that year, assuming that the numbers of these procedures were not yet substantially impacted by vaccination. The total cost of the screening program in 2010 (excluding administrative program overheads) was estimated to be A$194.8M. We estimated that a total of 1.7 million primary screening smears costing $96.7M were conducted, a further 188,900 smears costing $10.9M were conducted to follow-up low grade abnormalities, 70,900 colposcopy and 34,100 histological evaluations together costing $21.2M were conducted, and about 18,900 treatments for precancerous lesions were performed (including retreatments), associated with a cost of $45.5M for treatment and post-treatment follow-up. We also estimated that $20.5M was spent on work-up and treatment for approximately 761 women diagnosed with invasive cervical cancer. Overall, an estimated $23 was spent in 2010 for each adult woman in Australia on cervical screening program-related activities. Approximately half of the total cost of the screening program is spent on delivery of primary screening tests but the introduction of HPV vaccination, new technologies, increasing the interval and changing the age range of screening is expected to have a substantial impact on this expenditure, as well as having some impact on follow-up and management costs. These estimates provide a benchmark for future assessment of the impact of changes to screening program recommendations to the costs of cervical screening in Australia.
Publisher: Springer Science and Business Media LLC
Date: 04-07-2013
DOI: 10.1007/S10620-013-2750-6
Abstract: The effectiveness of endoscopic ultrasound-guided fine-needle aspiration increases with the number of needle passes but needle passes are also associated with increased risk of adverse events. The trade-off between needle passes and adequacy has not been well-characterized. The purpose of this study was to compare the risk-benefit tradeoff of different s ling protocols with and without rapid onsite evaluation (ROSE). We used a discrete-event simulation model to compare eight different s ling protocols. Each s ling protocol was simulated 10,000 times to obtain the average performance for each scenario. The per-pass adequacy rates, ROSE, accuracy of the assessor and s ling limits were varied to determine the impact of these factors on the number of needle passes and adequacy rates. Increasing per-class adequacy can be achieved at a cost of increased needle passes. S ling with ROSE achieved higher adequacy with fewer needle passes than policies using a fixed number of needle passes without ROSE. Variable s ling policies using ROSE generally achieve greater per-case adequacy with fewer needle passes than non-ROSE s ling policies using a fixed number of passes.
Publisher: Oxford University Press (OUP)
Date: 11-04-2011
DOI: 10.1093/NDT/GFR177
Abstract: Little is known about pre-dialysis patients' or family caregivers' preferences for dialysis modality and the reasons underlying their decisions. The aim of this study was to rank the most important characteristics of dialysis on which patients and caregivers make decisions about treatment. A mixed methods approach was used with groups of pre-dialysis patients (chronic kidney disease Stage 4/5), dialysis patients and family caregivers. Characteristics of dialysis were identified and ranked in idually and then consensus of the most important characteristics was determined within each group. Purposive s ling was used to recruit participants until data saturation was achieved. Transcripts of focus groups were coded and analysed to examine the rationale behind the ranking. Thirty-four participants from two Australian hospitals attended six 'nominal group' focus groups between September 2009 and February 2010. Two groups involved pre-dialysis patients (total n = 8), two involved peritoneal and haemodialysis patients, respectively (n = 9) and two involved caregivers of dialysis patients (n = 17). We identified 28 characteristics of dialysis important to patients and caregivers. Patient groups agreed that the most important characteristics were (i) survival, (ii) convenience of dialysis at home and (iii) dialysis-free days. For caregivers, the most important were (i) convenience of dialysis at home, (ii) respite and (iii) the ability to travel. Patients and family caregivers highly value treatment that enhances survival and can be performed at home. Future planning of dialysis services could better reflect these priorities through provision of increased home dialysis support services and planned respite for caregivers.
Publisher: Springer Science and Business Media LLC
Date: 27-09-2013
Abstract: An increasing number of falls result in an emergency call and the subsequent dispatch of paramedics. In the absence of physical injury, abnormal physiological parameters or change in usual functional status, it could be argued that routine conveyance by ambulance to the Emergency Department (ED) is not the most effective or efficient use of resources. Further, it is likely that non-conveyed older fallers have the potential to benefit from timely access to fall risk assessment and intervention. The aim of this randomised controlled trial is to evaluate the effect of a timely and tailored falls assessment and management intervention on the number of subsequent falls and fall-related injuries for non-conveyed older fallers. Community dwelling people aged 65 years or older who are not conveyed to the ED following a fall will be eligible to be visited at home by a research physiotherapist. Consenting participants will receive in idualised intervention strategies based on risk factors identified at baseline. All pre-test measures will be assessed prior to randomisation. Post-test measures will be undertaken by a researcher blinded to group allocation 6 months post-baseline. Participants in the intervention group will receive in idualised pro-active fall prevention strategies from the clinical researcher to ensure that risk factors are addressed adequately and interventions carried out. The primary outcome measure will be the number of falls recorded by a falls diary over a 12 month period. Secondary outcome measures assessed six months after baseline will include the subsequent use of medical and emergency services and uptake of recommendations. Data will be analysed using the intention-to-treat principle. As there is currently little evidence regarding the effectiveness or feasibility of alternate models of care following ambulance non-conveyance of older fallers, there is a need to explore assessment and intervention programs to help reduce subsequent falls, related injuries and subsequent use of health care services. By linking existing services rather than setting up new services, this pragmatic trial aims to utilise the health care system in an efficient and timely manner. Australian New Zealand Clinical Trials Registry: ACTRN%2012611000503921
Publisher: Public Library of Science (PLoS)
Date: 06-04-2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2017
Abstract: The relationship between increased hemodialysis hours and patient outcomes remains unclear. We randomized (1:1) 200 adult recipients of standard maintenance hemodialysis from in-center and home-based hemodialysis programs to extended weekly (≥24 hours) or standard (target 12–15 hours, maximum 18 hours) hemodialysis hours for 12 months. The primary outcome was change in quality of life from baseline assessed by the EuroQol 5 dimension instrument (3 level) (EQ-5D). Secondary outcomes included medication usage, clinical laboratory values, vascular access events, and change in left ventricular mass index. At 12 months, median weekly hemodialysis hours were 24.0 (interquartile range, 23.6–24.0) and 12.0 (interquartile range, 12.0–16.0) in the extended and standard groups, respectively. Change in EQ-5D score at study end did not differ between groups (mean difference, 0.04 [95% confidence interval, −0.03 to 0.11] P =0.29). Extended hours were associated with lower phosphate and potassium levels and higher hemoglobin levels. Blood pressure (BP) did not differ between groups at study end. Extended hours were associated with fewer BP-lowering agents and phosphate-binding medications, but were not associated with erythropoietin dosing. In a substudy with 95 patients, we detected no difference between groups in left ventricular mass index (mean difference, −6.0 [95% confidence interval, −14.8 to 2.7] g/m 2 P =0.18). Five deaths occurred in the extended group and two in the standard group ( P =0.44) two participants in each group withdrew consent. Similar numbers of patients experienced vascular access events in the two groups. Thus, extending weekly hemodialysis hours did not alter overall EQ-5D quality of life score, but was associated with improvement in some laboratory parameters and reductions in medication burden. (Clinicaltrials.gov identifier: NCT00649298).
Publisher: Elsevier BV
Date: 05-2015
DOI: 10.1053/J.AJKD.2014.12.017
Abstract: Biocompatible solutions may lower peritonitis rates, but are more costly than conventional solutions. The aim of the present study was to assess the additional costs and health outcomes of biocompatible over conventional solutions in incident peritoneal dialysis patients to guide practice decisions. Secondary economic evaluation of a randomized controlled trial. 185 participants in the balANZ trial. Cost-effectiveness of biocompatible compared to standard solution over the 2 years using an Australian health care funder perspective. Intervention group received biocompatible solutions and control group received standard solutions over 2 years. Costs included dialysis charges, costs of treating peritonitis, non-peritonitis-related hospital stays, and medication. Peritonitis was the health outcome of interest incremental cost-effectiveness ratios were reported in terms of the additional cost per additional patient avoiding peritonitis at 2 years. Mean total per-patient costs were A$57,451 and A$53,930 for the biocompatible and standard-solution groups, respectively. The base-case analysis indicated an incremental cost of A$17,804 per additional patient avoiding peritonitis at 2 years for biocompatible compared to standard solution. In a sensitivity analysis excluding extreme outliers for non-peritonitis-related hospitalizations, mean per-patient costs were A$49,159 and A$52,009 for the biocompatible and standard-solution groups, respectively. Consequently, the incremental cost-effectiveness ratio also was reduced significantly: biocompatible solution became both less costly and more effective than standard solution and, in economic terms, was dominant over standard solution. Peritonitis was a secondary outcome of the balANZ trial. Health outcomes measured only in terms of patients avoiding peritonitis over 2 years may underestimate the longer term benefits (eg, prolonged technique survival). Biocompatible dialysis solutions may offer a cost-effective alternative to standard solutions for peritoneal dialysis patients. Reductions in peritonitis-related hospital costs may offset the higher costs of biocompatible solution.
Publisher: Elsevier BV
Date: 2014
DOI: 10.1016/J.ARCHGER.2013.07.004
Abstract: In this paper we describe (i) the protocol for a cluster controlled clinical trial of nurse led care coordination in residential aged care facilities (RACF) and (ii) the development and content of a best practice resource guide to be implemented as part of this trial. We used published systematic reviews of quantitative studies, existing resources and multidisciplinary expert opinion to develop an intervention for testing in a cluster controlled trial (Australian and New Zealand Clinical Trials Registry Number 12611000933954). The trial will determine whether care coordination of multiple evidenced based strategies can improve quality of life and reduce hospitalization rates amongst people living in RACF. Central to the intervention arm of the trial are two components: (i) experienced nurse practitioners responsible for resident care and (ii) a best practice guide for the care processes being delivered and coordinated by those nurses. In this paper we outline how this practice guide, which is published herein, was refined through consultative processes and practitioner testing.
Publisher: Springer Science and Business Media LLC
Date: 07-06-2019
Publisher: Wiley
Date: 25-05-2010
DOI: 10.1111/J.1440-1797.2010.01294.X
Abstract: Decision-making in clinical practice is complex and getting more complex. There are a large range of alternative actions possible, all with different consequences and trade-offs. The complexity of medical decision-making is best illustrated using a clinical scenario.
Publisher: Elsevier BV
Date: 04-2022
DOI: 10.1053/J.AJKD.2021.07.011
Abstract: The risk of developing colorectal cancer in patients with chronic kidney disease (CKD) is twice that of the general population, but the factors associated with colorectal cancer are poorly understood. The aim of this study was to identify factors associated with advanced colorectal neoplasia in patients with CKD. Prospective cohort study. Patients with CKD stages 3-5, including those treated with maintenance dialysis or transplantation across 11 sites in Australia, New Zealand, Canada, and Spain, were screened for colorectal neoplasia using a fecal immunochemical test (FIT) as part of the Detecting Bowel Cancer in CKD (DETECT) Study. Baseline characteristics for patients at the time of study enrollment were ascertained, including duration of CKD, comorbidities, and medications. Advanced colorectal neoplasia was identified through a 2-step verification process with colonoscopy following positive FIT and 2-year clinical follow-up for all patients. Potential factors associated with advanced colorectal neoplasia were explored using multivariable logistic regression. Sensitivity analyses were performed using grouped LASSO (least absolute shrinkage and selection operator) logistic regression. Among 1,706 patients who received FIT-based screening-791 with CKD stages 3-5 not receiving kidney replacement therapy (KRT), 418 receiving dialysis, and 497 patients with a functioning kidney transplant-117 patients (6.9%) were detected to have advanced colorectal neoplasia (54 with CKD stages 3-5 without KRT, 34 receiving dialysis, and 29 transplant recipients), including 9 colorectal cancers. The factors found to be associated with advanced colorectal neoplasia included older age (OR per year older, 1.05 [95% CI, 1.03-1.07], P<0.001), male sex (OR, 2.27 [95% CI, 1.45-3.54], P<0.001), azathioprine use (OR, 2.99 [95% CI, 1.40-6.37], P=0.005), and erythropoiesis-stimulating agent use (OR, 1.92 [95% CI, 1.22-3.03], P=0.005). Grouped LASSO logistic regression revealed similar associations between these factors and advanced colorectal neoplasia. Unmeasured confounding factors. Older age, male sex, erythropoiesis-stimulating agents, and azathioprine were found to be significantly associated with advanced colorectal neoplasia in patients with CKD.
Publisher: Wiley
Date: 27-03-2014
DOI: 10.1002/OBY.20747
Abstract: To determine the costs and cost-effectiveness of an early childhood home visiting program delivered to families in socio-economically disadvantaged areas of Sydney, Australia during 2007-2010. Economic evaluation of a randomized controlled trial, the healthy beginnings (HB) trial, from the perspective of the health funder. Intervention resources were determined from local health district records in 2012 $AUD. Health-care resource utilization was determined through patient-level data linkage. The cost of HB intervention in the clinical trial over 2 years was $1309 per child (2012 $AUD). The incremental cost-effectiveness ratio was $4230 per unit BMI avoided and $631 per 0.1 reduction in BMI z-score. It was estimated that the program could be delivered in practice for $709 per child with incremental cost-effectiveness ratios of $2697 per unit BMI avoided and $376 per 0.1 reduction in BMI z-score. We present the first economic evaluation of an effective obesity prevention initiative in early childhood. HB is a moderately priced intervention with demonstrated effectiveness that offers similar or better value for money than existing obesity prevention or treatment interventions targeted at older children.
Publisher: Wiley
Date: 27-03-2019
DOI: 10.1111/NEP.13269
Abstract: Patients with chronic kidney disease (CKD) have an increased risk of cancer compared with the general population. Despite this, there is considerable variability in cancer screening practices among nephrologists that may reflect uncertainties about the benefits and harms of screening, the additional costs, and competing priorities among the complex issues that patients are confronted with. We aimed to describe nephrologists' perspectives and approaches to cancer screening in CKD. Semi-structured interviews were conducted with 29 nephrologists from 15 units across Australia and New Zealand. Interviews were transcribed and thematically analyzed. Five themes were identified: empowering patients to make informed decisions (respecting patient preferences, communicating evidence-based recommendations, creating awareness of consequences, preparing for transplantation) justifiable risk taking (avoiding undue consequences in vulnerable populations, balancing the costs and benefits, warranted by long term immunosuppression, assurance of reasonable survival gains) ambiguity of evidence in supporting decisions (absence of standardized recommendations, limited transferability of population-based data) depending on a shared multidisciplinary approach (collaboration with primary health care, access to coordinated skin cancer clinics) and prioritizing current or imminent complications. Nephrologists approach decisions about cancer screening in patients with CKD based on patient preferences, assessment of risk, justifiable survival gains, and current health priorities. Evidence-based guidelines, communication frameworks and specialist clinics may support informed and shared decision making about cancer screening in CKD.
Publisher: Elsevier BV
Date: 04-2021
Publisher: BMJ
Date: 27-10-2011
Publisher: SAGE Publications
Date: 23-03-2018
Abstract: To compare the cost effectiveness of two occupational therapy–led discharge planning interventions from the HOME trial. An economic evaluation was conducted within the superiority randomized HOME trial to assess the difference in costs and health-related outcomes associated with the enhanced program and the in-hospital consultation. Total costs of health and community service utilization were used to calculate incremental cost-effectiveness ratios, activities of daily living and quality-adjusted life years. Medical and acute care wards of Australian hospitals ( n=5). A total of 400 people ≥ 70 years of age. Participants were randomized to either (1) an enhanced program (HOME), involving pre ost discharge visits and two follow-up phone calls, or (2) an in-hospital consultation using the home and community environment assessment and the Lawton Instrumental Activities of Daily Living assessment. Nottingham Extended Activities of Daily Living (global measure of activities of daily living) and SF-12V2, transformed into SF-6D (quality-adjusted life year) measured at baseline and three months post discharge. The cost of the enhanced program was higher than that of the in-hospital consultation. However, a higher proportion of patients showed improvement in activities of daily living in the enhanced program with an incremental cost-effectiveness ratio of $61,906.00 per person with clinically meaningful improvement. Health services would not save money by implementing the enhanced program as a routine intervention in medical and acute care wards. Future research should incorporate longer time horizons and consider which patient groups would benefit from home visits.
Publisher: Public Library of Science (PLoS)
Date: 28-11-2017
Publisher: American Medical Association (AMA)
Date: 28-09-2009
DOI: 10.1001/ARCHINTERNMED.2009.282
Abstract: Information is needed to aid in idual decision making about prostate-specific antigen (PSA) screening. We aimed to provide such information for men aged 40, 50, 60, and 70 years at low, moderate, and high risk for prostate cancer. A Markov model compared patients with vs without annual PSA screening using a 20% relative risk (RR) reduction (RR = 0.8) in prostate cancer mortality as a best-case scenario. The model estimated numbers of biopsies, prostate cancers, and deaths from prostate cancer per 1000 men over 10 years and cumulated to age 85 years. Benefits and harms vary substantially with age and familial risk. Using 60-year-old men with low risk as an ex le, of 1000 men screened annually, we estimate that 115 men will undergo biopsy triggered by an abnormal PSA screen result and that 53 men will be diagnosed as having prostate cancer over 10 years compared with 23 men diagnosed as having prostate cancer among 1000 unscreened men. Among screened men, 3.5 will die of prostate cancer over 10 years compared with 4.4 deaths in unscreened men. For 1000 men screened from 40 to 69 years of age, there will be 27.9 prostate cancer deaths and 639.5 deaths overall by age 85 years compared with 29.9 prostate cancer deaths and 640.4 deaths overall in unscreened men. Higher-risk men have more prostate cancer deaths averted but also more prostate cancers diagnosed and related harms. Men should be informed of the likely benefits and harms of PSA screening. These estimates can be used to support in idual decision making.
Publisher: Wiley
Date: 04-2017
DOI: 10.1111/IMJ.13350
Abstract: Australians access anticancer drugs predominantly through the Pharmaceutical Benefits Scheme (PBS). To determine why the Pharmaceutical Benefits Advisory Committee (PBAC) rejects submissions to list anticancer drugs on the PBS. We reviewed publicly available information about submissions made to the PBAC for PBS listing of anticancer drugs from 2005 to 2014. Submission characteristics, including clinical and economic evidence, PBAC recommendations, and the reasons offered for rejection were recorded. Two reviewers independently categorised the reason for rejection offered by the PBAC. Logistic regression was used to determine submission characteristics associated with rejection. We identified 213 submissions for 110 unique indications of 60 anticancer drugs. The overall rejection rate was 56% (119/213). Of the 110 indications assessed, 69% (76/110) were rejected at least once. The annual rejection rate ranged from 50 to 73% with little evidence of a trend over time (P = 0.2). Submission characteristics strongly associated with rejection in multivariable analysis included: PBAC judged the clinical evidence to be problematic or uncertain (P < 0.001) PBAC judged the economic evidence to be problematic or uncertain (P < 0.001) and, inactive comparator used (P < 0.001). The most frequent reasons for rejection offered by the PBAC was 'inadequate cost-effectiveness or drug price too high' (75/109, 69%). Inadequate cost-effectiveness and PBAC uncertainty about the clinical and economic evidence were the most frequent reasons for rejection. Clarity of information about PBAC deliberations and their reasons for rejection are important for patients and doctors grappling with decisions about the use of expensive unfunded anticancer drugs.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 27-05-2014
Publisher: BMJ
Date: 2017
Publisher: Elsevier BV
Date: 12-2011
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 31-10-2019
DOI: 10.2215/CJN.06800619
Abstract: Little is known about the effect of changes in dialysis hours on patient-reported outcome measures. We report the effect of doubling dialysis hours on a range of patient-reported outcome measures in a randomized trial, overall and separately for important subgroups. The A Clinical Trial of IntensiVE Dialysis trial randomized 200 participants to extended or standard weekly hours hemodialysis for 12 months. Patient-reported outcome measures included two health utility scores (EuroQOL-5 Dimensions-3 Level, Short Form-6 Dimension) and their derived quality-adjusted life year estimates, two generic health scores (Short Form-36 Physical Component Summary, Mental Component Summary), and a disease-specific score (Kidney Disease Component Score). Outcomes were assessed as the mean difference from baseline using linear mixed effects models adjusted for time point and baseline score, with interaction terms added for subgroup analyses. Prespecified subgroups were dialysis location (home- versus institution-based), dialysis vintage (≤6 months versus months), region (China versus Australia, New Zealand, Canada), and baseline score (lowest, middle, highest tertile). Multiplicity-adjusted P values (Holm–Bonferroni) were calculated for the main analyses. Extended dialysis hours was associated with improvement in Short Form-6 Dimension (mean difference, 0.027 95% confidence interval [95% CI], 0.00 to 0.05 P =0.03) which was not significant after adjustment for multiple comparisons ( Padjusted =0.05). There were no significant differences in EuroQOL-5 Dimensions-3 Level health utility (mean difference, 0.036 95% CI, −0.02 to 0.09 P =0.2 Padjusted =0.2) or in quality-adjusted life years. There were small positive differences in generic and disease-specific quality of life: Physical Component Summary (mean difference, 2.3 95% CI, 0.6 to 4.1 P =0.01 Padjusted =0.04), Mental Component Summary (mean difference, 2.5 95% CI, 0.5 to 4.6 P =0.02 Padjusted =0.05) and Kidney Disease Component Score (mean difference, 3.5 95% CI, 1.5 to 5.5 P =0.001 Padjusted =0.005). The results did not differ among predefined subgroups or by baseline score. The effect of extended hours hemodialysis on patient-reported outcome measures reached statistical significance in some but not all measures. Within each measure the effect was consistent across predefined subgroups. The clinical importance of these differences is unclear.
Publisher: Springer Science and Business Media LLC
Date: 25-05-2011
Publisher: Springer Science and Business Media LLC
Date: 23-09-2015
Publisher: Oxford University Press (OUP)
Date: 25-11-2012
DOI: 10.1093/NDT/GFS490
Abstract: Despite the higher risk of colorectal cancer (CRC) in people with chronic kidney disease, it remains uncertain whether early detection through screening is cost-effective in this setting. We aimed to determine the costs and health benefits of CRC screening in people on dialysis or who have received a kidney transplant. Using a government health perspective, three probabilistic Markov models were constructed to compare the cost-effectiveness and cost-utility of annual immunochemical faecal occult blood test (iFOBT) screening against no-screening in a cohort of 1000 patients (age 50-70 years) on dialysis and with kidney transplants. A series of one-way, multi-way and probabilistic sensitivity analyses were conducted to assess the robustness of the model structure and the extent in which the model's assumptions were sensitive to the uncertainties within the input variables. The incremental cost-effectiveness ratios (ICERs) of CRC screening compared with no-screening were $138 828 per quality-adjusted life year [QALY $122 977 per life year saved (LYS)], $121 973 per QALY ($ 85 095 per LYS) and $44 790 per QALY ($25 036 per LYS) for dialysis patients not listed on the transplant waiting list, patients on the transplant waiting list and patients with kidney transplants, respectively. The test specificity of iFOBT, the starting age of screening and cancer prevalence were influential factors that determined the overall cost-effectiveness of screening in this setting. Screening for CRC using iFOBT may reduce cancer-specific mortality in patients on dialysis and with kidney transplants. However, the benefits and costs of screening CRCs in patients on dialysis, especially for those deemed not suitable for transplantation, greatly exceeded the typical thresholds for acceptable cost-effectiveness.
Publisher: Elsevier BV
Date: 02-2014
DOI: 10.1016/J.EJCA.2013.09.028
Abstract: Based on the clinical data, bevacizumab has been approved in Australia and globally for the treatment of advanced colorectal cancer. However, limited evidence exists for its cost-effectiveness. The purpose of this study was to evaluate the cost effectiveness of adding bevacizumab to capecitabine monotherapy in patients with metastatic colorectal cancer, using data from the prospective economic evaluation conducted alongside the MAX trial. In idual patient level data on resource use and progression free survival were prospectively collected in the phase III MAX trial. Resource use data were collected for the period between randomisation and disease progression, and unit costs were assigned from the perspective of the Australian health care funder. Effectiveness was measured in quality adjusted progression free survival years, with utility scores obtained from both the community valued EQ-5D questionnaire and the patient valued UBQ-C questionnaire. Progression free survival was used as a secondary effectiveness measure. The addition of bevacizumab to capecitabine monotherapy cost approximately $192,156 (95% confidence interval [CI], $135,619 to $326,894) per quality adjusted progression free survival year gained when using publicly listed pharmaceutical prices and utility values from the EQ-5D questionnaire. This decreased to $149,455 (95% CI, $100,356 to $245,910) when values from the UBQ-C questionnaire were applied. The incremental cost per progression free survival year was $145,059 (95% CI, $106,703 to $233,225). Bevacizumab was not found to be cost effective at its listed price, based on results from the MAX trial.
Publisher: Oxford University Press (OUP)
Date: 27-12-2021
DOI: 10.1093/NDT/GFAB360
Abstract: Despite an increased cancer risk for patients with chronic kidney disease (CKD), uptake of cancer screening varies due to competing priorities and complex health-related issues. This study aimed to elicit the preferences and important attributes of cancer screening in patients with CKD. An on-line best–worst scaling survey was used to ascertain the relative importance of 22 screening attributes among CKD patients using an incomplete block design. Preference scores (0–1) were calculated by multinomial logistic regression. Preference heterogeneity was evaluated. The survey was completed by 83 patients: 26 not requiring kidney replacement therapy, 20 receiving dialysis and 37 transplant recipients (mean age 59 years, 53% men, 75% prior to cancer screening). The five most important attributes were early detection {preference score 1.0 [95% confidence interval (CI) 0.90–1.10]}, decreased risk of cancer death [0.85 (0.75–0.94)], false negatives [0.71 (0.61–0.80)], reduction in immunosuppression if detected [0.68 (0.59–0.78)] and non-invasive interventions after positive results [0.68 (0.59–0.78)]. Preference heterogeneity reflected the stage of CKD. Immunosuppression reduction [mean difference 0.11 (95% CI 0.02–0.19)] and views of family/friends [0.10 (reference attribute)] were important for transplant recipients. Screening frequency [−0.18 (95% CI −0.26 to −0.10)] and overdiagnosis of harmless cancers [−0.14 (95% CI −0.22 to −0.10)] were important for dialysis patients. Early detection, risk of cancer-related death, false negatives, immunosuppression reduction and non-invasive interventions following detection are important cancer screening considerations among CKD patients. Patient preferences are key to shared decision-making and in idualized cancer screening.
Publisher: Elsevier BV
Date: 2015
DOI: 10.1016/J.JPHYS.2014.11.001
Abstract: What relative value do older people with a previous fall or mobility-related disability attach to different attributes of exercise? Prospective, best-worst scaling study. Two hundred and twenty community-dwelling people, aged 60 years or older, who presented with a previous fall or mobility-related disability. Online or face-to-face questionnaire. Utility values for different exercise attributes and levels. The utility levels were calculated by asking participants to select the attribute that they considered to be the best (ie, they were most likely to want to participate in programs with this attribute) and worst (ie, least likely to want to participate). The attributes included were: exercise type time spent on exercise per day frequency transport type travel time out-of-pocket costs reduction in the chance of falling and improvement in the ability to undertake tasks inside and outside of home. The attributes of exercise programs with the highest utility values were: home-based exercise and no need to use transport, followed by an improvement of 60% in the ability to do daily tasks at home, no costs, and decreasing the chances of falling to 0%. The attributes with the lowest utility were travel time of 30 minutes or more and out-of-pocket costs of AUD50 per session. The type of exercise, travel time and costs are more highly valued by older people than the health benefits. These findings suggest that physical activity engagement strategies need to go beyond education about health benefits and focus on improving accessibility to exercise programs. Exercise that can be undertaken at or close to home without any cost is most likely to be taken up by older people with past falls and/or mobility-related disability.
Publisher: Wiley
Date: 30-06-2015
DOI: 10.1002/MDC3.12208
Publisher: Oxford University Press (OUP)
Date: 20-10-2010
DOI: 10.1093/NDT/GFQ627
Abstract: Renal cancer is the most common solid organ cancer in the kidney transplant population with an excess risk ~ 5-fold greater than the general population. It is uncertain whether routine screening for renal cancer is cost-effective. The aim of our study is to estimate the costs and health benefits of ultrasonographic (US) screening for renal cancer in the kidney transplant population. A Markov model was developed to compare the costs and benefits in a cohort of kidney transplant recipients (n = 1000, aged 18-69 years), who underwent annual and biennial US screening for renal cancer, compared with a cohort that did not. For recipients of kidney transplants aged 18-69 years, the incremental cost-effectiveness ratio (ICER) for routine US screening ranged from $252,100/LYS for biennial screening to $320,988/LYS for annual screening. A total of two and one cancer deaths were averted in the annually and biennially screened population, with a relative cancer-specific mortality reduction by 25% and 12.5%, respectively. Using a series of sensitivity analyses, the ICER was most sensitive to the costs and test specificity of ultrasonography, prevalence of disease, and the risk of graft failure in the screened population. Routine screening for renal cancer may reduce the risk of cancer-related deaths in recipients of kidney transplants. Uncertainties, however, exist in the model's influential variables including the risk of graft failure among those who received contrast-enhanced diagnostic computer tomography. Given the available evidence, routine screening for renal cancers may not be cost-effective for recipients of kidney transplants.
Publisher: Springer Science and Business Media LLC
Date: 10-05-2016
DOI: 10.1007/S11136-016-1311-9
Abstract: Indigenous conceptions of health have been shown to differ from that of their non-Indigenous counterparts. As a result, there remains uncertainty over the appropriateness and value of using existing health-related quality-of-life (HRQoL) instruments in Indigenous communities. The objective of this review was to identify studies that either measure the HRQoL of an Indigenous population or validated a measure used to elicit the HRQoL in an Indigenous population. A systematic review of the published literature was conducted to (1) investigate the extent to which HRQoL instruments are used in Indigenous populations (2) to identify which instruments have been validated in which populations and (3) to identify which instruments have been tailored for use with Indigenous populations. Forty-one studies were included in the review. Only three of the 41 studies utilised Indigenous-specific instruments. The remainder (38 studies) utilised generic population or disease-specific instruments. Four studies found specific HRQoL instruments to be valid in these populations and 32 estimated the HRQoL of an Indigenous population. The limited ex les of Indigenous-specific instruments highlighted the potential importance to the HRQoL of these populations of domains that lie outside of traditional measures including social and community domains as well as domains relating to culture, diet and land use on top of more traditional HRQoL domains. Ensuring that the HRQoL of Indigenous populations is being appropriately measured is vital to prioritising available resources to the most effective interventions. HRQoL instruments present an opportunity to directly elicit and incorporate Indigenous preferences and conceptions of health into these decisions. Further work is required in the field to ensure that this potential is realised.
Publisher: Springer Science and Business Media LLC
Date: 19-08-2015
Publisher: Springer Science and Business Media LLC
Date: 15-04-2020
DOI: 10.1186/S12882-020-01776-Y
Abstract: Chronic kidney disease is an increasingly common health problem for Aboriginal and Torres Strait Islander people. It is associated with multiple concurrent psychosocial stressors frequently resulting in negative impacts on emotional and social wellbeing. There is need for well-designed intervention studies to provide evidence of effective treatment for comorbid depression or other mental illness in this setting. Attention to early phase piloting and development work is recommended when testing complex interventions. This paper documents feasibility testing and adaptation of an existing culturally responsive brief wellbeing intervention, the Stay Strong App, and three commonly used wellbeing outcome measures, in preparation for a clinical trial testing effectiveness of the intervention. The Stay Strong App, which has not been used in the setting of Chronic Kidney Disease before, is reviewed and adapted for people with comorbid wellbeing concerns through expert consensus between research team and an Expert Panel. The outcome measures (Kessler 10, Patient Health Questionnaire 9, and EuroQoL) are valid, reliable, and commonly used tools to assess various aspects of wellbeing, which have also not been used in this context before. Feasibility and acceptability are examined and developed through 3 stages: Pilot testing in a purposive s le of five haemodialysis patients and carers translation of outcome measures through collaboration between the Aboriginal Interpreter Service, Aboriginal and Torres Strait Islander research officers and the research team and conversion of translated outcome measures to electronic format. Research team and expert panel consensus led to adaptation of the Stay Strong App for renal patients through selective revision of words and images. Pilot testing identified challenges in delivery of the wellbeing measures leading to word changes and additional prompts, integration of audio translations in 11 local Indigenous languages within an interactive Outcome Measures App, and related research protocol changes. Modelling the complex intervention prior to full-scale testing provided important information about the design of both the outcome measures and the intervention. These changes are likely to better support success in conduct of the clinical trial and future implementation of the intervention in clinical settings.
Publisher: Wiley
Date: 25-03-2014
DOI: 10.1111/NEP.12385
Abstract: Observational reports suggest extended dialysis hours are associated with improved outcomes. These findings are confounded by better prognostic characteristics among people practising extended hours. The aim of this article is to provide an overview of the methods and baseline characteristics for ACTIVE Dialysis Study participants. This multicentre, randomized, open-label, blinded endpoint-assessment trial randomized participants receiving maintenance haemodialysis therapy to either extended (≥24 h) or standard (12-18 h) weekly haemodialysis for 12 months. A web-based randomization system used minimization to ensure balanced allocation across regions, dialysis setting and dialysis vintage. The primary outcome is the change in quality of life over 12 months of study treatment assessed by EQ-5D. Secondary outcomes include change in left ventricular mass index assessed by magnetic resonance imaging and safety outcomes including dialysis access events. A total of 200 participants were recruited between 2009 and 2013 from Australia (29.0%), China (62.0%), Canada (5.5%) and New Zealand (3.5%). Participants had a mean age of 52 (± 12) years and 11.5% were dialysing at home, with a mean duration of 13.9 h per week over a median of three sessions. At baseline, 32.5% had a history of cardiovascular disease and 36.5% had diabetes. The ACTIVE Dialysis Study has met its planned recruitment target. The participant population are drawn from a range of health service settings in a global context. The study will contribute important evidence on the benefits and harms of extending weekly dialysis hours. The trial is registered at clinicaltrials.gov (NCT00649298).
Publisher: Wiley
Date: 05-11-2022
DOI: 10.1111/ANS.18134
Abstract: Given the cost differential between surgical and non‐surgical management of distal radius fractures, we aimed to evaluate the cost‐effectiveness of surgical compared with non‐surgical treatment of distal radius fractures in a cohort of older patients. This evaluation was conducted alongside the combined randomized and observational study of surgery for fractures of the distal radius in the elderly (CROSSFIRE) trial (ACTRN 12616000969460) which compared surgical (open reduction and internal fixation using volar‐locking plate (VLP) fixation) and non‐surgical (closed fracture reduction and cast immobilization (CR)) treatment for displaced distal radius fractures in patients ≥60 years. Cost‐effectiveness was assessed from the perspective of the public hospital funder. Hospital records from a sub‐s le of participants were used to estimate costs. Outcomes were patient‐reported wrist pain and function questionnaire (PRWE) scores and quality adjusted life years (QALYs) calculated using the EuroQoL five‐dimension five‐level tool (EQ‐5D‐5L). From 166 participants (81 surgical, 85 non‐surgical), costs were obtained for 56 (29 surgical, 27 non‐surgical). The mean costs for VLP fixation were Australian dollars (AUD) 6668 (95% CI $4857 to $8479) compared to AUD 3343 (95% CI $1304 to $5381) for CR. The incremental cost‐effectiveness ratios (ICER) to achieve a 1‐point improvement in the PRWE were AUD 375, AUD 1736 and AUD 1126 at 3, 12 and 24 months for VLP compared with CR. At 12 months, the cost effectiveness was dominated by CR (lower cost and better QoL) whereas at 24 months, the incremental cost per QALY gained by VLP was AUD 1 946 127. In the treatment of distal radius fractures in patients ≥60 years, VLP fixation was not cost‐effective compared with CR from the perspective of hospital funders.
Publisher: Wiley
Date: 25-07-2014
DOI: 10.1111/NEP.12269
Abstract: The financial burden of the increasing dialysis population challenges healthcare resources internationally. Home haemodialysis offers many benefits over conventional facility dialysis including superior clinical, patient-centred outcomes and reduced cost. This review updates a previous review, conducted a decade prior, incorporating contemporary home dialysis techniques of frequent and nocturnal dialysis. We sought comparative cost-effectiveness studies of home versus facility haemodialysis (HD) for people with end-stage kidney failure (ESKF). We conducted a systematic review of literature from January 2000-March 2014. Studies were included if they provided comparative information on the costs, health outcomes and cost-effectiveness ratios of home HD and facility HD. We searched medical and health economic databases using MeSH headings and text words for economic evaluation and haemodialysis. Six studies of economic evaluations that compared home to facility HD were identified. Two studies compared home nocturnal HD, one home nocturnal and daily home HD, and three compared contemporary home HD to facility HD. Overall these studies suggest that contemporary home HD modalities are less costly and more effective than facility HD. Home HD start-up costs tend to be higher in the short term, but these are offset by cost savings over the longer term. Contemporaneous dialysis modalities including nocturnal and daily home haemodialysis are cost-effective or cost-saving compared with facility-based haemodialysis. This result is largely driven by lower staff costs, and better health outcomes for survival and quality of life. Expanding the proportion of haemodialysis patients managed at home is likely to produce cost savings.
Publisher: Wiley
Date: 2008
DOI: 10.1002/HEC.1278
Abstract: A two-stage standard gamble was used to evaluate women's preferences for alternative managements of atypical squamous cells of undermined significance (ASCUS) on Pap smear (repeat Pap smear compared with immediate HPV test), and to test for the evidence of process utility. Women's utilities for the health state scenarios were clustered towards the upper end of the 0-1 scale with considerable variability in women's preferences. There was evidence of process utility, with immediate human papillomavirus (HPV) testing strategies having lower valuations than repeat Pap smear, where the clinical outcome was the same. Mean (95% CI) utilities for HPV testing (negative test) followed by resolution were 0.9967 (0.9957-0.9978) compared with repeat Pap smear followed by resolution: 0.9972 (0.9964-0.9980). Mean (95% CI) utilities for immediate HPV testing (positive test), followed by colposcopy, biopsy and treatment were 0.9354 (0.8544-1.0) compared with repeat Pap smear followed by colposcopy, biopsy and treatment: 0.9656 (0.9081-1.0). Our results add to the existing evidence that the impact of healthcare interventions on well-being is not limited to the effect of the intervention on the health outcomes expected from the intervention process of care can have quality of life implications for the in idual. A modelled application of trial-based data will allow characterisation of the true population costs, benefits, risks and harms of alternative triage strategies and subsequent policy implications thereof.
Publisher: Springer Science and Business Media LLC
Date: 18-04-2016
Publisher: CSIRO Publishing
Date: 2017
DOI: 10.1071/AH15221
Abstract: Objectives The aim of the present study was to describe community views and perspectives on public engagement processes in Australian health technology assessment (HTA) decision making. Methods Six focus groups were held in Sydney (NSW, Australia) as part of a broad program of work on public engagement and HTA. Eligible participants were aged ≥18 years and spoke English. Participants were asked about their views and perspectives of public engagement in the HTA decision-making process, with responses analysed using a public participation framework. Results Fifty-eight participants aged 19–71 years attended the focus groups. Responses from the public indicated that they wanted public engagement in HTA to include a ersity of in iduals, be independent and transparent, involve in iduals early in the process and ensure that public input is meaningful and useful to the process. This was consistent with the public participation framework. Perceived shortcomings of the current public engagement process were also identified, namely the lack of awareness of the HTA system in the general population and the need to acknowledge the role different groups of stakeholders or ‘publics’ can have in the process. Conclusions The public do see a role for themselves in the HTA decision-making process. This is distinct to the involvement of patients and carers. It is important that any future public engagement strategy in this field distinguishes between stakeholder groups and outline approaches that will involve members of the public in the decision-making process, especially if public expectations of involvement in healthcare decision-making continue to increase. What is known about this topic? The views and perspectives of patients and consumers are important in the HTA decision-making process. There is a move to involve the broader community, particularly as decisions become increasingly complex and resources more scarce. What does this paper add? It not been known to what extent, or at what points, the community would like to be engaged with the HTA decision-making process. The present study adds to the evidence base on this topic by identifying features of engagement that may be important in determining the extent of wider public involvement. It is clear that the community expects the system to be transparent, for patients to be involved early in specific processes and the wider community to be able to contribute to the broader vision of the healthcare system. What are the implications for practitioners? A formalised strategy is needed to include the public voice into health technology decisions. With the current level of reform in the healthcare sector and the focus on creating a sustainable healthcare system, there is a real opportunity to implement an approach that not only informs patients and the community of the challenges, but includes and incorporates their views into these decisions. This will assist in developing and adapting policy that is relevant and meets the needs of the population.
Publisher: Wiley
Date: 1995
Publisher: Oxford University Press (OUP)
Date: 25-11-2012
DOI: 10.1093/NDT/GFS487
Abstract: Iron supplementation can be administered either intravenously or orally in patients with chronic kidney disease (CKD) and iron deficiency anaemia, but practice varies widely. The aim of this study was to estimate the health care costs and benefits of parenteral iron compared with oral iron in haemodialysis patients receiving erythropoiesis-stimulating agents (ESAs). Using broad health care funder perspective, a probabilistic Markov model was constructed to compare the cost-effectiveness and cost-utility of parenteral iron therapy versus oral iron for the management of haemodialysis patients with relative iron deficiency. A series of one-way, multi-way and probabilistic sensitivity analyses were conducted to assess the robustness of the model structure and the extent in which the model's assumptions were sensitive to the uncertainties within the input variables. Compared with oral iron, the incremental cost-effectiveness ratios (ICERs) for parenteral iron were $74,760 per life year saved and $34,660 per quality-adjusted life year (QALY) gained. A series of one-way sensitivity analyses show that the ICER is most sensitive to the probability of achieving haemoglobin (Hb) targets using supplemental iron with a consequential decrease in the standard ESA doses and the relative increased risk in all-cause mortality associated with low Hb levels (Hb < 9.0 g/dL). If the willingness-to-pay threshold was set at $50,000/QALY, the proportions of simulations that showed parenteral iron was cost-effective compared with oral iron were over 90%. Assuming that there is an overall increased mortality risk associated with very low Hb level (<9.0 g/dL), using parenteral iron to achieve an Hb target between 9.5 and 12 g/L is cost-effective compared with oral iron therapy among haemodialysis patients with relative iron deficiency.
Publisher: BMJ
Date: 19-01-2010
DOI: 10.1136/BMJ.C112
Publisher: Elsevier BV
Date: 2018
DOI: 10.2139/SSRN.3258663
Publisher: Public Library of Science (PLoS)
Date: 02-09-2014
Publisher: Springer Science and Business Media LLC
Date: 25-06-2019
Publisher: Elsevier BV
Date: 08-2015
DOI: 10.1053/J.AJKD.2015.02.341
Abstract: Research aims to improve health outcomes for patients. However, the setting of research priorities is usually performed by clinicians, academics, and funders, with little involvement of patients or caregivers and using processes that lack transparency. A national workshop was convened in Australia to generate and prioritize research questions in chronic kidney disease (CKD) among erse stakeholder groups. Patients with CKD (n=23), nephrologists/surgeons (n=16), nurses (n=8), caregivers (n=7), and allied health professionals and researchers (n=4) generated and voted on intervention questions across 4 treatment categories: CKD stages 1 to 5 (non-dialysis dependent), peritoneal dialysis, hemodialysis, and kidney transplantation. The 5 highest ranking questions (in descending order) were as follows: How effective are lifestyle programs for preventing deteriorating kidney function in early CKD? What strategies will improve family consent for deceased donor kidney donation, taking different cultural groups into account? What interventions can improve long-term post-transplant outcomes? What are effective interventions for post hemodialysis fatigue? How can we improve and in idualize drug therapy to control post-transplant side effects? Priority questions were focused on prevention, lifestyle, quality of life, and long-term impact. These prioritized research questions can inform funding agencies, patient/consumer organizations, policy makers, and researchers in developing a CKD research agenda that is relevant to key stakeholders.
Publisher: Springer Science and Business Media LLC
Date: 27-05-2022
Publisher: BMJ
Date: 27-10-2022
DOI: 10.1136/BJSPORTS-2022-105747
Abstract: To investigate cost-effectiveness and costs of fall prevention exercise programmes for older adults. Systematic review. Medline, Embase, Web of Science, Scopus, National Institute for Health Research Economic Evaluation Database, Health Technology Assessment database, Tufts Cost-Effectiveness Analysis Registry, Research Papers in Economics and EconLit (inception to May 2022). Economic evaluations (trial-based or model-based) and costing studies investigating fall prevention exercise programmes versus no intervention or usual care for older adults living in the community or care facilities, and reporting incremental cost-effectiveness ratio (ICER) for fall-related outcomes or quality-adjusted life years (QALY, expressed as cost/QALY) and/or intervention costs. 31 studies were included. For community-dwelling older adults (21 economic evaluations, 6 costing studies), results ranged from more effective and less costly (dominant) interventions up to an ICER of US$279 802/QALY gained and US$11 986/fall prevented (US$ in 2020). Assuming an arbitrary willingness-to-pay threshold (US$100 000/QALY), most results (17/24) were considered cost-effective (moderate certainty). The greatest value for money (lower ICER/QALY gained and fall prevented) appeared to accrue for older adults and those with high fall risk, but unsupervised exercise appeared to offer poor value for money (higher ICER/QALY). For care facilities (two economic evaluations, two costing studies), ICERs ranged from dominant (low certainty) to US$35/fall prevented (moderate certainty). Overall, intervention costs varied and were poorly reported. Most economic evaluations investigated fall prevention exercise programmes for older adults living in the community. There is moderate certainty evidence that fall prevention exercise programmes are likely to be cost-effective. The evidence for older adults living in care facilities is more limited but promising. PROSPERO 2020 CRD42020178023.
Publisher: Oxford University Press (OUP)
Date: 05-06-2013
DOI: 10.1093/NDT/GFT208
Abstract: Solid organ transplantation is the treatment of choice for those with organ failure, but suitable organs are a limited community resource. Little is known about community preferences for the allocation of those organs. We aimed to determine community preferences for organ allocation and reasons for their choices. Participants were recruited from the community in four states in Australia. In focus groups, they identified and discussed attributes that they believed were important for allocating organs to potential recipients. Transcripts were analysed thematically. Thirteen focus groups with 114 participants were conducted. Four major themes emerged: (i) saving and improving the lives (ii) lowering the risk of lost opportunities (iii) fairness and (iv) accountability. While happy to discuss general principles, many were not comfortable making organ allocation decisions and were happy to defer to health professionals this reticence tended to disappear when discussing the use of their own organs. Participants wanted to save as many lives as possible as well as lower the risk of lost opportunities for those on the waiting list by maximizing the chances of success of every donation. A rational utilitarian ethical model of organ allocation, therefore, appeared to be the dominant framework adopted by the community. Key considerations were compatibility, high chance of peri-operative survival and favouring those with positive lifestyle and self-management choices. Communication between the transplant community and general community about organ allocation could be undertaken to create trust and shared understanding, which may ultimately increase organ donation rates in the future.
Publisher: Elsevier BV
Date: 03-2008
Publisher: Springer Science and Business Media LLC
Date: 10-01-2022
Publisher: BMJ
Date: 2013
Publisher: Elsevier BV
Date: 10-2009
Publisher: BMJ
Date: 05-2016
Publisher: Springer Science and Business Media LLC
Date: 27-09-2022
DOI: 10.1007/S12687-021-00551-2
Abstract: The Medical Services Advisory Committee (MSAC) is an independent non-statutory committee established by the Australian government to provide recommendations on public reimbursement of technologies and services, other than pharmaceuticals. MSAC has established approaches for undertaking health technology assessment (HTA) of investigative services and codependent technologies. In 2016, MSAC published its clinical utility card (CUC) Proforma, an additional tool to guide assessments of genetic testing for heritable conditions. We undertook a review and narrative synthesis of information extracted from all MSAC assessments of genetic testing for heritable conditions completed since 2016, regardless of the HTA approach taken. Ten assessments met our inclusion criteria, covering a range of testing methods (from gene panels to whole-exome sequencing) and purposes (including molecular diagnosis, genetic risk assessment, identification of congenital anomaly syndromes, and carrier screening). This analysis identified a range of methodological and policy challenges such as how to incorporate patient and societal preferences for the health and non-health outcomes of genomic testing, how best to capture the concept of co-production of utility, and how to engage clinicians as referrers for genomics tests whilst at the same time ensuring equity of access to a geographically dispersed population. A further challenge related to how qualitative assessments of patient and community needs influenced the evidence thresholds against which decisions were made. These concepts should be considered for incorporation within the value assessment frameworks used by HTA agencies around the world.
Publisher: BMJ
Date: 07-10-2020
DOI: 10.1136/INJURYPREV-2020-043915
Abstract: Older Aboriginal people have a strong leadership role in their community including passing on knowledge and teachings around culture and connections to Country. Falls significantly affect older people and are a growing concern for older Aboriginal people and their families. Regular participation in balance and strength exercise has been shown to be efficacious in reducing falls. A pilot study developed in partnership with Aboriginal communities, the Ironbark: Standing Strong and Tall programme, demonstrated high community acceptability and feasibility, and gains in balance and strength in Aboriginal participants. This cluster randomised controlled trial will assess the effectiveness of the programme in reducing the rate of falls in older Aboriginal people. We will examine the effectiveness and cost-effectiveness of the Ironbark group-based fall prevention programme compared with a group-based social programme, with Aboriginal people aged 45 years and older in three Australian states. The primary outcome is fall rates over 12 months, measured using weekly self-reported data. Secondary outcomes measured at baseline and after 12 months include quality of life, psychological distress, activities of daily living, physical activity, functional mobility and central obesity. Differences between study groups in the primary and secondary outcomes at 12 months will be estimated. This is the first trial to investigate the effectiveness and cost-effectiveness of a fall prevention programme for Aboriginal peoples aged ≥45 years. The study has strong cultural and community governance, including Aboriginal investigators and staff, and is guided by a steering committee that includes representatives of Aboriginal community-controlled services. ACTRN12619000349145.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 27-01-2012
Publisher: BMJ
Date: 17-07-2018
DOI: 10.1136/ARCHDISCHILD-2018-314934
Abstract: The aim was to compare quality of life (QoL) among children and adolescents with different stages of chronic kidney disease (CKD) and determine factors associated with changes in QoL. Cross-sectional. The Kids with CKD study involved five of eight paediatric nephrology units in Australia and New Zealand. There were 375 children and adolescents (aged 6–18 years) with CKD, on dialysis or transplanted, recruited between 2013 and 2016. Overall and domain-specific QoL were measured using the Health Utilities Index 3 score, with a scale from −0.36 (worse than dead) to 1 (perfect health). QoL scores were compared between CKD stages using the Mann-Whitney U test. Factors associated with changes in QoL were assessed using multivariable linear and ordinal logistic regression. QoL for those with CKD stages 1–2 (n=106, median 0.88, IQR 0.63–0.96) was higher than those on dialysis (n=43, median 0.67, IQR 0.39–0.91, p .001), and similar to those with kidney transplants (n=135, median 0.83, IQR 0.59–0.97, p=0.4) or CKD stages 3–5 (n=91, 0.85, IQR 0.60–0.98). Reductions were most frequent in the domains of cognition (50%), pain (42%) and emotion (40%). The risk factors associated with decrements in overall QoL were being on dialysis (decrement of 0.13, 95% CI 0.02 to 0.25, p=0.02), lower family income (decrement of 0.10, 95% CI 0.03 to 0.15, p=0.002) and short stature (decrement of 0.09, 95% CI 0.01 to 0.16, p=0.02). The overall QoL and domains such as pain and emotion are substantially worse in children on dialysis compared with earlier stage CKD and those with kidney transplants.
Publisher: Springer Science and Business Media LLC
Date: 03-05-2017
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 27-05-2012
Publisher: Springer Science and Business Media LLC
Date: 21-03-2014
DOI: 10.1007/S40271-014-0054-3
Abstract: It is well established that screening is effective in reducing the incidence and mortality associated with colorectal cancer (CRC). National screening programs have been implemented in many countries however, uptake remains an issue. Understanding patient preferences may assist in shaping screening programs and tailoring information about screening tests. Our objective was to undertake a systematic review of discrete choice experiments (DCEs) of CRC screening. A systematic review of DCEs of CRC screening was undertaken in an average-risk general population. The methodological qualities of the studies were assessed using a standard checklist outlining best practice for conjoint studies. Nine studies met the selection criteria. Meta-analysis was not possible due to the heterogeneity of the data and methods. However, in eight studies, attributes describing accuracy and/or clinical effectiveness were reported to be statistically significant. We also found that in iduals were willing to trade-off other attributes such as an increased risk of complications to gain greater clinical benefits. Screening was also preferred to non-screening by the majority of respondents, regardless of the test used. Understanding and incorporating in iduals' preferences in decision making is increasingly considered essential in the health field. Data from DCEs can provide valuable insights into the trade-offs in iduals are willing to undertake in respect to CRC screening. Such insights can be used by decision makers to identify screening tests that could maximize informed uptake. It is likely that, with better reporting and evolving methodology, the contribution that DCEs can make to such debates will increase.
Publisher: Elsevier BV
Date: 10-2003
DOI: 10.1111/J.1467-842X.2003.TB00824.X
Abstract: To evaluate the type of information that is available to purchasers of home-based bowel cancer test kits. Manufacturers, pharmacies and independent testing programs were contacted to obtain faecal occult blood test (FOBT) kits. State cancer organisations were contacted for information on bowel cancer screening. Information on bowel cancer, the FOBT kit, the testing process and potential benefits and harms of the screening process were assessed using guidelines provided by the UK General Medical Council (GMC). FOBT kits and cancer organisation information provided adequate information on the purpose of screening, the screening process itself and potential benefits, but provided no information concerning uncertainties of screening or potential harms. On the basis of both the UK GMC criteria and patient desires for information, the information available at present falls short of being considered adequate for an informed decision to purchase a home-based FOBT. We must ensure adequate and balanced information is available to redress the present information asymmetry to facilitate informed participation in a potentially valuable public health initiative.
Publisher: Wiley
Date: 02-2009
DOI: 10.1111/J.1440-1797.2008.01073.X
Abstract: Renal replacement therapy (RRT) consumes sizable proportions of health budgets internationally, but there is considerable variability in choice of RRT modality among and within countries with major implications for health outcomes and costs. We aimed to quantify these implications for increasing kidney transplantation and improving the rate of home-based dialysis. A multiple cohort Markov model was used to assess costs and health outcomes of RRT for new end-stage kidney disease (ESKD) patients in Australia for 2005-2010, using a health-care funder perspective. Patient characteristics and current practice patterns were based on the ANZDATA Registry. Two proposed changes were modelled: (i) increasing kidney transplants by between 10% and 50% by 2010 and (ii) increasing home haemodialysis (HD) and peritoneal dialysis (PD) to the highest rates observed among Australian centres. We assessed costs (Australian dollars), survival and quality-adjusted survival, and cost-effectiveness. The number of new ESKD patients in 2010 was estimated to be 2700, with annual RRT costs of about $A700 million cumulative costs (2005-2010) were $A5 billion. Increasing transplants by 10-50% saves between $A5.8 and $A26.2 million, and increases quality-adjusted life years (QALYs) by 130-658 QALYs. Switching new patients from hospital HD to (i) home HD saves $A46.6 million by 2010 or (ii) PD saves $A122.1 million. These clinical practice changes reduce costs, improve patient quality of life and, in the case of transplantation, increase survival. Planning for RRT services should incorporate efforts to maximize rates of transplantation and to encourage home-based over hospital-based dialysis to optimize cost-effectiveness in RRT service delivery.
Publisher: BMJ
Date: 11-2020
DOI: 10.1136/BMJOPEN-2019-034696
Abstract: Mobility limitation is common and often results from neurological and musculoskeletal health conditions, ageing and/or physical inactivity. In consultation with consumers, clinicians and policymakers, we have developed two affordable and scalable intervention packages designed to enhance physical activity for adults with self-reported mobility limitations. Both are based on behaviour change theories and involve tailored advice from physiotherapists. This pragmatic hybrid effectiveness-implementation type 1 randomised control trial (n=600) will be undertaken among adults with self-reported mobility limitations. It aims to estimate the effects on physical activity of: (1) an enhanced 6-month intervention package (one face-to-face physiotherapy assessment, tailored physical activity plan, physical activity phone coaching from a physiotherapist, informational/motivational resources and activity monitors) compared with a less intensive 6-month intervention package (single session of tailored phone advice from a physiotherapist, tailored physical activity plan, unidirectional text messages, informational/motivational resources) (2) the enhanced intervention package compared with no intervention (6-month waiting list control group) and (3) the less intensive intervention package compared with no intervention (waiting list control group). The primary outcome will be average steps per day, measured with the StepWatch Activity Monitor over a 1-week period, 6 months after randomisation. Secondary outcomes include other physical activity measures, measures of health and functioning, in idualised mobility goal attainment, mental well-being, quality of life, rate of falls, health utilisation and intervention evaluation. The hybrid effectiveness-implementation design (type 1) will be used to enable the collection of secondary implementation outcomes at the same time as the primary effectiveness outcome. An economic analysis will estimate the cost-effectiveness and cost-utility of the interventions compared with no intervention and to each other. Ethical approval has been obtained by Sydney Local Health District, Royal Prince Alfred Zone. Dissemination will be via publications, conferences, newsletters, talks and meetings with health managers. ACTRN12618001983291.
Publisher: Oxford University Press (OUP)
Date: 25-10-2017
Abstract: approximately 25% of older people who fall and receive paramedic care are not subsequently transported to an emergency department (ED). These people are at high risk of future falls, unplanned healthcare use and poor health outcomes. to evaluate the impact of a fall-risk assessment and tailored fall prevention interventions among older community-dwellers not transported to ED following a fall on subsequent falls and health service use. Randomised controlled trial involving 221 non-transported older fallers from Sydney, Australia. the intervention targeted identified risk factors and used existing services to implement physiotherapy, occupational therapy, geriatric assessment, optometry and medication management interventions as appropriate. The control group received in idualised written fall prevention advice. primary outcome measures were rates of falls and injurious falls. Secondary outcome measures were ambulance re-attendance, ED presentation, hospitalisation and quality of life over 12 months. Analysis was by intention-to-treat and per-protocol according to self-reported adherence using negative binominal regression and multivariate analysis. ITT analysis showed no significant difference between groups in subsequent falls, injurious falls and health service use. The per-protocol analyses revealed that the intervention participants who adhered to the recommended interventions had significantly lower rates of falls compared to non-adherers (IRR: 0.53 (95% CI : 0.32-0.87)). a multidisciplinary intervention did not prevent falls in older people who received paramedic care but were not transported to ED. However the intervention was effective in those who adhered to the recommendations. the trial is registered at the Australian New Zealand Clinical Trials Registry: ACTRN 12611000503921, 13/05/2011.
Publisher: Wiley
Date: 31-01-2011
DOI: 10.1111/J.1399-3046.2010.01470.X
Abstract: This study aimed to explore experiences and perspectives of adolescent kidney transplant recipients following kidney transplantation. We conducted 22 in-depth, face-to-face interviews with adolescent kidney transplant recipients (aged 12-19 yr) from five Australian pediatric transplant units. We analyzed the interview transcripts for descriptive and analytical themes. The overarching theme was achieving a sense of normality. Having the same opportunities and potential to achieve as other adolescents facilitated better adjustment, well-being and positive development after transplant. Five facilitators and five barriers to achieving a sense of normality were identified. The facilitators were developing their own identity, peer acceptance, making medications routine, freedom and energy, and support structures. The barriers included identity crisis, peer rejection, aversion to medications, lifestyle limitations, and fear and uncertainty. The adolescents felt more knowledge was needed on the technical, medical, and experiential aspects of transplantation and on pertinent issues such as alcohol, drugs, and substance use. Adolescent kidney transplant recipients value normality and have specific information needs about the effect of kidney transplantation on their physical appearance and the tolerance of drugs and alcohol. Novel approaches are needed to foster self-confidence and sense of normality and to provide comprehensive information on the patient journey following kidney transplantation.
Publisher: Wiley
Date: 27-08-1970
DOI: 10.1111/J.1440-1797.2010.01340.X
Abstract: The new CARI guidelines for 'Acceptance onto dialysis' suggest patients with chronic kidney disease are referred to a nephrologist at an estimated glomerular filtration rate of <30 ml/min per 1.73 m², to allow 3-6 months for pre-dialysis education, creation of dialysis access, and planned initiation of renal replacement therapy or conservative management. Similarly, international guidelines recommend education for patients and their families occurs 6 to 12 months prior to the predicted onset of end stage kidney disease or during Stage 4 or Stage 5 chronic kidney disease. However, some patients commencing treatment may not receive information about their options at a time that facilitates effective and informed decision making or that enables consideration of treatment other than centre-based haemodialysis. Implementation of chronic kidney disease education guidelines has not been widely reported and there are few published studies that assess the provision and delivery of information about all treatment options. Patient INformation about Options for Treatment (PINOT) is a prospective national audit of the type and timing of information provided by renal units to incident pre-emptive transplant, dialysis and conservatively managed patients over a 3-month period. PINOT will assess the patient and unit characteristics associated with timely information provision and highlight any regional variation in treatments offered.
Publisher: Elsevier BV
Date: 12-2016
Publisher: Springer Science and Business Media LLC
Date: 05-06-2012
Publisher: Cambridge University Press (CUP)
Date: 2006
DOI: 10.1017/S0266462306050902
Abstract: Background: Endoscopic retrograde cholangiopancreatography (ERCP) is considered the gold standard for imaging of the biliary tract but is associated with complications. Less invasive imaging techniques, such as magnetic resonance cholangiopancreatography (MRCP), have a much lower complication rate. The accuracy of MRCP is comparable to that of ERCP, and MRCP may be more effective and cost-effective, particularly in cases for which the suspected prevalence of disease is low and further intervention can be avoided. A model was constructed to compare the effectiveness and cost-effectiveness of MRCP and ERCP in patients with a previous history of cholecystectomy, presenting with abdominal pain and/or abnormal liver function tests. Methods: Diagnostic accuracy estimates came from a systematic review of MRCP. A decision analytic model was constructed to represent the diagnostic and treatment pathway of this patient group. The model compared the following two diagnostic strategies: (i) MRCP followed with ERCP if positive, and then management based on ERCP and (ii) ERCP only. Deterministic and probabilistic analyses were used to assess the likelihood of MRCP being cost-effective. Sensitivity analyses examined the impact of prior probabilities of common bile duct stones (CBDS) and test performance characteristics. The outcomes considered were costs, quality-adjusted life years (QALYs), and cost per additional QALY. Results: The deterministic analysis indicated that MRCP was dominant over ERCP. At prior probabilities of CBDS, less than 60 percent MRCP was the less costly initial diagnostic test above this threshold, ERCP was less costly. Similarly, at probabilities of CBDS less than 68 percent, MRCP was also the more effective strategy (generated more QALYs). Above this threshold, ERCP became the more effective strategy. Probabilistic sensitivity analyses indicated that, in this patient group for which there is a low to moderate probability of CBDS, there was a 59 percent likelihood that MRCP was cost-saving, an 83 percent chance that MRCP was more effective with a higher quality adjusted survival, and an 83 percent chance that MRCP had a cost-effectiveness ratio more favorable than $50,000 per QALY gained. Conclusions: Costs and cost-effectiveness are dependent upon the prior probability of CBDS. However, probabilistic analysis indicated that, with a high degree of certainty, MRCP was the more effective and cost-effective initial test in postcholecystectomy patients with a low to moderate probability of CBDS.
Publisher: Wiley
Date: 19-03-2013
DOI: 10.1111/GGI.12053
Abstract: If developing policies to optimize quality acute care within residential aged care facilities (RACF) is a goal, understanding the factors that influence the decision to transfer a resident from RACF to hospital emergency departments is important. The aim of the present study was to review the published literature pertaining to transfer decisions. We carried out a systematic review of the qualitative literature to ascertain key influences on transfer decisions amongst three key stakeholder groups - residents, their family and carers. From 11 papers we found two themes encompassing seven domains of influence. Transfers are influenced by an expectation or goal of improved resident clinical or quality of life outcomes - these are domains within the "resident dominant" theme. However, transfers also occur where there is no expectation of resident benefit. These domains, such as inadequate facility resourcing and care planning, are categorized within the "resident subordinate" theme. Transfer decisions are often influenced by considerations beyond expected benefit to the in idual resident. Conceptualizing influences on transfer decisions within this framework might assist clinicians and policy makers in the design and delivery of services for RACF residents.
Publisher: BMJ
Date: 10-03-2021
DOI: 10.1136/BMJQS-2020-012337
Abstract: Overuse of lumbar imaging is common in the emergency department (ED). Few trials have examined interventions to address this. We evaluated the effectiveness of a multifaceted intervention to implement guideline recommendations for low back pain in the emergency department. We conducted a stepped-wedge, cluster-randomised trial in four EDs in New South Wales, Australia. After a 13-month control phase of usual care, the EDs received a multifaceted intervention to support guideline-endorsed care in a random order, based on a computer-generated random sequence, every 4 weeks over a 4-month period. All sites were followed up for at least 3 months. The primary outcome was the proportion of low back pain presentations receiving lumbar imaging. Secondary healthcare utilisation outcomes included prescriptions of opioid and non-opioid pain medicines, inpatient admissions, length of ED stay, specialist referrals and re-presentations. Clinician beliefs and knowledge about low back pain care were measured before and after the intervention. Patient-reported pain, disability, quality of life and satisfaction were measured at 1, 2 and 4 weeks post ED presentation. A total of 269 ED clinicians and 4625 episodes of care for low back pain (4491 patients) were included. The data did not provide clear evidence that the intervention reduced lumbar imaging (OR 0.77 95% CI 0.47 to 1.26 p=0.29). It did reduce opioid use (OR 0.57 95% CI 0.38 to 0.85 p=0.006) and improved clinicians’ beliefs (mean difference (MD), 2.85 95% CI 1.85 to 3.85 p .001 on a scale from 9 to 45) and knowledge about low back pain care (MD, 0.48 95% CI 0.13 to 0.83 p .01 on a scale from 0 to 11). There was no difference in pain scores at 1-week follow-up (MD, 0.04 95% CI −1.00 to 1.08 p=0.94 on a scale from 0 to 10). A similar trend was observed for all other patient-reported outcomes and time points. This study found no effect on the other secondary healthcare utilisation outcomes. It is uncertain if a multifaceted intervention to implement guideline recommendations for low back pain care decreased lumbar imaging in the ED however, it did reduce opioid prescriptions without adversely affecting patient outcomes. Trial registration number ACTRN12617001160325.
Publisher: Springer Science and Business Media LLC
Date: 10-09-2021
DOI: 10.1186/S12885-021-08752-1
Abstract: Adjuvant immunotherapy is revolutionising care for patients with resected stage III and IV melanoma. However, immunotherapy may be associated with toxicity, making treatment decisions complicated. This study aimed to identify factors physicians and nurses considered regarding adjuvant immunotherapy for melanoma. In-depth interviews were conducted with physicians (medical oncologists, surgeons and dermatologists) and nurses managing patients with resected stage III melanoma at three Australian tertiary melanoma centres between July 2019 and March 2020. Factors considered regarding adjuvant immunotherapy were explored. Recruitment continued until data saturation and thematic analysis was undertaken. Twenty-five physicians and nurses, aged 28–68 years, 60% females, including eleven (44%) medical oncologists, eight (32%) surgeons, five (20%) nurses, and one (4%) dermatologist were interviewed. Over half the s le managed five or more new resected stage III patients per month who could be eligible for adjuvant immunotherapy. Three themes about adjuvant immunotherapy recommendations emerged: [1] clinical and patient factors, [2] treatment information provision, and [3] in idual physician/nurse factors. Melanoma sub-stage and an in idual patient’s therapy risk/benefit profile were primary considerations. Secondary factors included uncertainty about adjuvant immunotherapy’s effectiveness and their views about treatment burden patients might consider acceptable. Patients’ disease sub-stage and their treatment risk versus benefit drove the melanoma health care professionals’ adjuvant immunotherapy endorsement. Findings clarify clinician preferences and values, aiding clinical communication with patients and facilitating clinical decision-making about management options for resected stage III melanoma.
Publisher: Springer Science and Business Media LLC
Date: 03-05-2023
Publisher: Elsevier BV
Date: 2021
Publisher: Wiley
Date: 28-12-2012
DOI: 10.1111/J.1440-1797.2011.01531.X
Abstract: To estimate the utility-based quality of life (QOL) of people with chronic kidney disease (CKD) and to estimate the QOL associated with two hypothetical colorectal cancer health states. A cross-sectional study was conducted in people with CKD (stages 3-5, transplant recipients and those on dialysis) from three centres in Sydney, Australia. We measured participants' own QOL and that of two hypothetical colorectal cancer health states using a rating scale, and a utility-based QOL measure, the time trade-off, with extremes of 0 (death) and 1 (full health). Recipients of kidney transplants (n=79) had the highest mean QOL weights of 0.79 (standard deviation (SD)=0.34) compared with participants with CKD 3-5 (n=53) with mean QOL weights of 0.70 (SD=0.39), and those on dialysis (n=89), who had the lowest mean QOL weights of 0.62 (SD=0.41) (P=0.02). Having early and advanced stage colorectal cancers were valued at mean QOL weights of 0.44 (SD=0.41) and 0.12 (SD=0.25) among people with moderate stage CKD 0.45 (SD=0.39) and 0.11 (SD=0.24) among dialysis patients 0.62 (SD=0.36) and 0.18 (SD=0.29) among kidney transplant recipients. People with CKD have poor QOL. Having coexistent illnesses such as cancer further reduces the overall well-being of in iduals with kidney disease. In addition to the development of effective screening and treatment programs to improve cancer outcomes in people with CKD, our study also highlights the need for effective interventions to improve the QOL in people with CKD, particularly those with major comorbidities like cancer.
Publisher: Oxford University Press (OUP)
Date: 11-07-2022
Abstract: Electronic health record-based clinical decision support (CDS) has the potential to improve health outcomes. This systematic review investigates the design, effectiveness, and economic outcomes of CDS targeting several common chronic diseases. We conducted a search in PubMed (Medline), EBSCOHOST (CINAHL, APA PsychInfo, EconLit), and Web of Science. We limited the search to studies from 2011 to 2021. Studies were included if the CDS was electronic health record-based and targeted one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolemia. Studies with effectiveness or economic outcomes were considered for inclusion, and a meta-analysis was conducted. The review included 76 studies with effectiveness outcomes and 9 with economic outcomes. Of the effectiveness studies, 63% described a positive outcome that favored the CDS intervention group. However, meta-analysis demonstrated that effect sizes were heterogenous and small, with limited clinical and statistical significance. Of the economic studies, most full economic evaluations (n = 5) used a modeled analysis approach. Cost-effectiveness of CDS varied widely between studies, with an estimated incremental cost-effectiveness ratio ranging between USD$2192 to USD$151 955 per QALY. We summarize contemporary chronic disease CDS designs and evaluation results. The effectiveness and cost-effectiveness results for CDS interventions are highly heterogeneous, likely due to differences in implementation context and evaluation methodology. Improved quality of reporting, particularly from modeled economic evaluations, would assist decision makers to better interpret and utilize results from these primary research studies. PROSPERO (CRD42020203716)
Publisher: BMJ
Date: 06-2017
Publisher: Springer Singapore
Date: 2019
Publisher: BMJ
Date: 2012
Publisher: SAGE Publications
Date: 13-02-2015
Abstract: Background: Polypill-based strategies have improved patient use of preventive cardiovascular disease (CVD) medications in clinical trials. Continued use in real-world settings relies on patients preferring a polypill over current treatment. Objective: Within a clinical trial assessing a CVD polypill-based strategy on patient adherence (Kanyini Guidelines Adherence with the Polypill study [Kanyini GAP]), we used discrete choice experiment (DCE) to assess the influence of polypill-based treatment attributes and patient characteristics on preferences for CVD preventive treatment. Methods: A DCE survey was administered to Kanyini GAP participants, involving choices between 2 hypothetical treatment options and no treatment for CVD prevention. Attributes delineating a polypill from current treatment were assessed: out-of-pocket costs, tablet number, administration, and prescriber visit frequency. The odds ratios (ORs) for preferring treatment, trade-off between treatment-related attributes, and willingness to pay against other attributes were estimated. Results: In all, 332 of 487 (68%) participants completed the survey. Active treatment, compared with no treatment, was chosen by 93%. Treatment preference decreased with increasing out-of-pocket cost (OR = 0.04 95% CI = 0.03-0.05) and tablet number (OR = 0.69 95% CI = 0.59-0.81). Out-of-pocket cost was the most important attribute. Respondents were willing to pay $3.45 per month for each tablet reduction. Education and household income significantly influenced treatment preference. Conclusions: Assuming equivalent efficacy and safety of treatment options, the treatment-specific attributes that were assessed and influenced patient preference strongly accord with the posited advantages of the cardiovascular polypill. The study provides promising evidence that improvements in treatment adherence observed in CVD polypill trials may translate to the real world and potentially close treatment gaps in CVD prevention.
Publisher: Elsevier BV
Date: 03-2009
DOI: 10.1111/J.1524-4733.2008.00417.X
Abstract: Recent reviews of discrete choice methodology identified methodological issues warranting further exploration, including the issue of "framing." The objective of this study was to conduct a methodological exploration of the effect of attribute framing on marginal rates of substitution (MRS), including willingness to pay (WTP) from a discrete choice experiment (DCE), within the context of colorectal cancer screening preferences. The survey, a fractional factorial design of a two-alternative, unlabeled experiment, was mailed to a s le of 1920 subjects in NSW, Australia. Participants were randomized to one of four alternative "frames" of information. Attributes included: accuracy of the test for finding cancers, accuracy of the test for finding large polyps, how good the test is at saying you don't have cancer, cost, dietary and medication restrictions and s le collection. A mixed logit model was used to estimate preferences MRS between attributes, including WTP, was calculated. A total of 1157 surveys from 1920 (60.2%) were returned. Accuracy of the test for finding cancer was most likely to influence choice of test, followed by accuracy of the test for finding large polyps. Under some circumstances, framing of the attributes (e.g., cancers found vs. cancers missed) influenced the relative importance of attributes. Attribute framing significantly influenced estimates of WTP, and benefit: harm trade-offs that were calculated from MRS. Attribute framing can influence willingness to pay and benefit: harm trade-offs from DCEs. Appropriate design and analysis methods should be explored to further characterize the influence and extent of framing in discrete choice studies.
Publisher: American Society of Clinical Oncology (ASCO)
Date: 10-12-2011
Abstract: To develop more evidence-based guidelines for the frequency of patient follow-up after treatment of localized (American Joint Committee on Cancer [AJCC] stage I or II) melanoma. We used data from Melanoma Institute Australia on an inception cohort of 3,081 consecutive patients first diagnosed with stage I or II melanoma between January 1985 and December 2009. Kaplan-Meier curves and Cox models were used to characterize the time course and predictors for recurrence and new primaries. We modeled the delay in diagnosis of recurrence or new primary as well as the number of monitoring visits required using two monitoring schedules: first, according to 2008 Australian and New Zealand guidelines and, second, with fewer visits, especially for those at lowest risk of recurrence. For every 1,000 patients beginning follow-up, 229 developed recurrence and 61 developed new primary within 10 years. There was only a small difference in modeled delay in diagnosis (extra 44.9 and 9.6 patients per 1,000 for recurrence and new primary, respectively, with delay greater than 2 months) using a schedule that requires far fewer visits (3,000 fewer visits per 1,000 patients) than recommended by current guidelines. AJCC substage was the most important predictor of recurrence, whereas age and date of primary diagnosis were important predictors of developing new primary. By providing less intensive monitoring, more efficient follow-up strategies are possible. Fewer visits with a more focused approach may address the needs of patients and clinicians to detect recurrent or new melanoma.
Publisher: CSIRO Publishing
Date: 08-12-2022
DOI: 10.1071/AH22120
Abstract: Objectives To determine the total annual screening and further-investigation costs of investigating false-positive and true-positive mammograms in the Australian population breast-screening program. Methods This economic analysis used aggregate-level retrospective cohort data of women screened at a breast-screening clinic. Counts and frequencies of each diagnostic workup-sequence recorded were scaled up to national figures and costed by estimating per-patient costs of procedures using screening clinic cost data. Main outcomes and measures estimated were percentage share of total annual screening and further-investigation costs for the Australian population breast-screening program of investigating false-positive and true-positive mammograms. Secondary outcomes determined were average costs of investigating each false-positive and true-positive mammogram. Sensitivity analyses involved recalculating results excluding subgroups of patients below and above the screening age range of 50–74 years. Results Of 8235 patients, the median age was 60.35 years with interquartile range of 54.17–67.17 years. A total of 15.4% (ranging from 13.4 to 15.4% under different scenarios) of total annual screening and further-investigation costs were from investigating false-positive mammograms. This exceeded the share of costs from investigating true-positives (13%). Conclusions We have developed a transparent and non-onerous approach for estimating the costs of false-positive and true-positive mammograms associated with the national breast-screening program. While determining an optimal balance between false-positives and true-positive rates must rely primarily on health outcomes, costs are an important consideration. We recommend that future research adopts and refines similar approaches to facilitate better monitoring of these costs, benchmark against estimates from other screening programs, and support optimal policy development.
Publisher: Springer Science and Business Media LLC
Date: 12-2014
Publisher: Elsevier BV
Date: 04-2019
DOI: 10.1016/J.IJMEDINF.2019.01.013
Abstract: To describe the range of patients' beliefs, attitudes, expectations, and experiences of remote monitoring for chronic conditions across different healthcare contexts and populations. We searched MEDLINE, Embase, PsychINFO, and CINAHL, Google Scholar, and reference lists of related studies through to July 2017. Thematic synthesis was used to analyse the findings of the primary studies. Study characteristics were examined to explain differences in findings. All healthcare settings PARTICIPANTS: Adults with chronic diseases OUTCOMES: Patient beliefs, attitudes, expectations and experiences of remote monitoring RESULTS: We included 16 studies involving 307 participants with chronic obstructive pulmonary disease, heart failure, diabetes, hypertension, and end stage kidney disease. The studies were conducted in 8 countries. We identified four themes: gaining knowledge and triggering actions (tracking and responding to change, prompting timely and accessible care, supporting self-management and shared decision-making) reassurance and security (safety in being alone, peace of mind) concern about additional burden (reluctance to learn something new, lack of trust in technology, avoiding additional out-of-pocket costs), and jeopardising interpersonal connections (fear of being lost in data, losing face to face contact). For patients with chronic disease, remote monitoring increased their disease-specific knowledge, triggered earlier clinical assessment and treatment, improved self-management and shared decision-making. However, these potential benefits were balanced against concerns about losing interpersonal contact, and the additional personal responsibility of remote monitoring.
Publisher: Springer Science and Business Media LLC
Date: 09-2011
DOI: 10.2165/11587070-000000000-00000
Abstract: Annalisa© (AL) is a web-based decision-support template grounded in multi-criteria decision analysis (MCDA). It uses a simple expected value algorithm to calculate a score for each option by taking into account the in idual's preferences for different criteria (as importance weights) and the evidence of the performance of each option on each criterion. Given the uncertainty surrounding the trade offs between benefits and harms for prostate cancer screening, this topic was chosen as the vehicle to introduce this new decision-support template. The aim of the study was to introduce a new decision-support template, AL, and to develop and pilot a decision-support tool for prostate cancer screening using it. A decision-support tool for prostate cancer screening (ALProst) was implemented in the AL template. ALProst incorporated evidence on both the benefits and the potential harms of prostate cancer screening (the 'attributes') from published randomized controlled trials (RCTs). In idual weights for each attribute were elicited during interviews. By combining the in idual's preferences and the evidence, the best option for the user was identified on the basis of quantified scores. A convenience s le of computer-proficient primary-care physicians (general practitioners [GPs] in Australia) from the Sydney Metropolitan area (Australia) were invited to complete a face-to-face interview involving the decision-support tool. Preference for undergoing prostate-specific antigen testing for prostate cancer, both personally and for their patients, was sought prior to seeing the tool. After gaining hands-on experience with using the tool, GPs were asked to comment on the merits of the template and the tool. Preference for presenting the benefits of prostate cancer screening as the relative or absolute risk reduction in prostate cancer-specific mortality was also sought. Of 60 GPs approached, ten (six men and four women) completed an interview (16.7% response rate). Most GPs agreed/strongly agreed with positive statements about the ease with which they could use AL (seven GPs), and understand the information in, and format of, AL (nine and eight, respectively). Eight agreed/strongly agreed that ALProst would be a useful tool for discussing prostate cancer screening with their patients. GPs were also asked to nominate difficult clinical decisions that they, and their patients, have had to make responses included cancer screening (including prostate cancer) treating patients with multiple illnesses/diseases managing multiple cardiovascular disease risk factors and managing patients who are receiving multiple medications. The common element was the need to consider multiple factors in making these complex decisions. AL is distinguishable from most other decision-support templates available today by its underlying conceptual framework, MCDA, and its power to combine in idual preferences with evidence to derive the best option for the user quantitatively. It therefore becomes potentially useful for all decisions at all levels in the healthcare system. Moreover, it will provide a universal graphic 'language' that can overcome the burden to patients of encountering a plethora of widely varying decision aids for different conditions during their lifetime.
Publisher: Frontiers Media SA
Date: 12-04-2014
DOI: 10.1111/TRI.12307
Abstract: Rates of transplantation from deceased donors remain low, despite high rates of expressed support. We aimed to better understand this mismatch through determining community attitudes regarding willingness to register as organ donors. Participants were recruited from the general public in four Australian states. Using nominal group techniques, participants ranked factors they believed were important when deciding to register as a deceased donor. Thirteen nominal groups with 114 participants were conducted. 24 factors were ranked by three or more groups. The top ten factors were as follows: saving lives, own decision to donate, family opinions, benefit to recipients, process of organ donation, positive media, positive closure, clarity of consent and body dignity. Other factors included: the consent system, religious and cultural beliefs and incentives for donation. Participant age was a potential modifier of responses. Willingness to register as an organ donor is highly influenced by the altruistic motive of saving lives and improving lives for others this should be harnessed in communication c aigns. Further research on ethical incentives for organ donation and continued efforts to promote support from religious groups may be useful. Many believe the sole right to consent to donation is theirs and not their families consent policies reflecting this should be explored.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-10-2016
DOI: 10.2215/CJN.11861115
Abstract: We aimed to determine the proportion of patients who switched to dialysis after confirmed plans for conservative care and compare survival and end-of-life care among patients choosing conservative care with those initiating RRT. A cohort study of 721 patients on incident dialysis, patients receiving transplants, and conservatively managed patients from 66 Australian renal units entered into the Patient Information about Options for Treatment Study from July 1 to September 30, 2009 were followed for 3 years. A two–sided binomial test assessed the proportion of patients who switched from conservative care to RRT. Cox regression, stratified by center and adjusted for patient and treatment characteristics, estimated factors associated with 3-year survival. In total, 102 of 721 patients planned for conservative care, and median age was 80 years old. Of these, 8% (95% confidence interval, 3% to 13%), switched to dialysis, predominantly for symptom management. Of 94 patients remaining on a conservative pathway, 18% were alive at 3 years. Of the total 721 patients, 247 (34%) died by study end. In multivariable analysis, factors associated with all-cause mortality included older age (hazard ratio, 1.55 95% confidence interval, 1.36 to 1.77), baseline serum albumin .0 versus 3.7–5.4 g/dl (hazard ratio, 4.31 95% confidence interval, 2.72 to 6.81), and management with conservative care compared with RRT (hazard ratio, 2.18 95% confidence interval, 1.39 to 3.40). Of 247 deaths, patients managed with RRT were less likely to receive specialist palliative care (26% versus 57% P .001), more likely to die in the hospital (66% versus 42% P .001) than home or hospice, and more likely to receive palliative care only within the last week of life (42% versus 15% P .001) than those managed conservatively. Survival after 3 years of conservative management is common, with relatively few patients switching to dialysis. Specialist palliative care services are used more frequently and at an earlier time point for conservatively managed patients, a practice associated with better symptom management and quality of life.
Publisher: American Medical Association (AMA)
Date: 03-2021
Publisher: Wiley
Date: 16-11-2017
DOI: 10.1111/NEP.12920
Abstract: There is little research exploring the association between clinicians' behaviours and home dialysis uptake. This paper aims to better understand the influence of clinicians on home dialysis modality recommendations and uptake. Online survey of all NZ renal units to determine the influence of in iduals within pre-dialysis teams. We used the self-declaration scale of influence to rate the identified member's perceived influence on decision-making. We used this measure of 'decisional power' to compare the perceived influence of pre-dialysis nurses with nephrologists using both parametric and non-parametric methods. We developed a generalized linear model to investigate the relationship between the influence of nephrologists and pre-dialysis nurses with home dialysis uptake by in idual centre using additional data from Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). Finally, respondents rated the importance of a list of patient and service-level factors in recommendations for home dialysis. Data suggest the nephrologists are the most influential member of the pre-dialysis team. This contrasts with perceptions of survey respondents who view pre-dialysis nurses as most influential. Nephrologists' recommendations are likely to be a successful way of increasing home dialysis. A single point increase in nephrologist decisional power is associated with a 6.1% increase in the prevalence of home dialysis. The decisional power around home dialysis in NZ sits with nephrologists. It is therefore critical that nephrologists exercise their decisional power in advocating home dialysis and address reasons why they may not recommend home dialysis to well-suited and appropriate patients.
Publisher: Springer Science and Business Media LLC
Date: 20-10-2022
Publisher: MDPI AG
Date: 28-05-2021
Abstract: Despite the health improvements afforded to non-Indigenous peoples in Canada, Aotearoa (New Zealand) and the United States, the Indigenous peoples in these countries continue to endure disproportionately high rates of mortality and morbidity. Indigenous peoples’ concepts and understanding of health and wellbeing are holistic however, due to their erse social, political, cultural, environmental and economic contexts within and across countries, wellbeing is not experienced uniformly across all Indigenous populations. We aim to identify aspects of wellbeing important to the Indigenous people in Canada, Aotearoa and the United States. We searched CINAHL, Embase, PsycINFO and PubMed databases for papers that included key Indigenous and wellbeing search terms from database inception to April 2020. Papers that included a focus on Indigenous adults residing in Canada, Aotearoa and the United States, and that included empirical qualitative data that described at least one aspect of wellbeing were eligible. Data were analysed using the stages of thematic development recommended by Thomas and Harden for thematic synthesis of qualitative research. Our search resulted in 2669 papers being screened for eligibility. Following full-text screening, 100 papers were deemed eligible for inclusion (Aotearoa (New Zealand) n = 16, Canada n = 43, United States n = 41). Themes varied across countries however, identity, connection, balance and self-determination were common aspects of wellbeing. Having this broader understanding of wellbeing across these cultures can inform decisions made about public health actions and resources.
Publisher: Emerald
Date: 19-09-2016
DOI: 10.1108/JHOM-08-2015-0119
Abstract: Public engagement in health technology assessment (HTA) is increasingly considered crucial for good decision making. Determining the “right” type of engagement activity is key in achieving the appropriate consideration of public values. Little is known about the factors that determine how HTA organizations (HTAOs) decide on their method of public engagement, and there are a number of possible factors that might shape these decisions. The purpose of this paper is to understand the potential drivers of public engagement from an organizational perspective. The published HTA literature is reviewed alongside existing frameworks of public engagement in order to elucidate key factors influencing the choice of public engagement process undertaken by HTAOs. A conceptual framework is then developed to illustrate the factors identified from the literature that appear to influence public engagement choice. Determining the type of public engagement undertaken in HTA is based on multiple factors, some of which are not always explicitly acknowledged. These factors included the: perceived complexity of the policy-making issue, perceived impact of the decision, transparency and opportunities for public involvement in governance, as well as time and resource constraints. The influences of these factors vary depending on the context, indicating that a one size fits all approach to public engagement may not be effective. Awareness of the various factors that might influence the type of public engagement undertaken would enable decision makers to reflect on their choices and be more accountable and transparent about their choice of engagement process in eliciting public values and preferences in a HTAO.
Publisher: BMJ
Date: 04-08-2005
Publisher: Public Library of Science (PLoS)
Date: 18-01-2012
Publisher: Elsevier BV
Date: 09-2016
DOI: 10.1053/J.AJKD.2016.02.037
Abstract: In the context of clinical research, investigators have historically selected the outcomes that they consider to be important, but these are often discordant with patients' priorities. Efforts to define and report patient-centered outcomes are gaining momentum, though little work has been done in nephrology. We aimed to identify patient and caregiver priorities for outcomes in hemodialysis. Nominal group technique. Patients on hemodialysis therapy and their caregivers were purposively s led from 4 dialysis units in Australia (Sydney and Melbourne) and 7 dialysis units in Canada (Calgary). Identification and ranking of outcomes. Mean rank score (of 10) for top 10 outcomes and thematic analysis. 82 participants (58 patients, 24 caregivers) aged 24 to 87 (mean, 58.4) years in 12 nominal groups identified 68 outcomes. The 10 top-ranked outcomes were fatigue/energy (mean rank score, 4.5), survival (defined by patients as resilience and coping 3.7), ability to travel (3.6), dialysis-free time (3.3), impact on family (3.2), ability to work (2.5), sleep (2.3), anxiety/stress (2.1), decrease in blood pressure (2.0), and lack of appetite/taste (1.9). Mortality ranked only 14th and was not regarded as the complement of survival. Caregivers ranked mortality, anxiety, and depression higher than patients, whereas patients ranked ability to work higher. Four themes underpinned their rankings: living well, ability to control outcomes, tangible and experiential relevance, and severity and intrusiveness. Only English-speaking participants were eligible. Although trials in hemodialysis have typically focused on outcomes such as death, adverse events, and biological markers, patients tend to prioritize outcomes that are more relevant to their daily living and well-being. Researchers need to consider interventions that are likely to improve these outcomes and measure and report patient-relevant outcomes in trials, and clinicians may become more patient-orientated by using these outcomes in their clinical encounters.
Publisher: Elsevier BV
Date: 12-2020
Publisher: Elsevier BV
Date: 04-2022
Publisher: Springer Science and Business Media LLC
Date: 02-02-2016
Publisher: Oxford University Press (OUP)
Date: 03-2013
Abstract: The effectiveness of fine-needle aspiration (FNA) increases with the number of needle passes, but needle passes are also associated with increased risk of adverse events. The trade-off between needle passes and adequacy has not been well characterized. Clinical studies are limited because of their inherent variability and limited s le size. We developed mathematical models to compare the performance of a variety of s ling protocols under a wide range of conditions. Specifically, we compared the performance of s ling methods using a fixed number of needle passes with s ling methods using a rapid onsite evaluation (ROSE) with a variable number of needle passes. Variable s ling with ROSE generally required fewer needle passes than fixed s le size policies to achieve a desired adequacy rate. Variable s ling policies using ROSE achieve greater per-case adequacy with fewer needle passes than s ling policies using a fixed number of passes if assessor accuracy is high.
Publisher: Elsevier BV
Date: 05-2009
DOI: 10.1016/J.JHEP.2008.12.022
Abstract: In Australia, Asian-born populations are 6-12 times more likely to develop hepatocellular cancer (HCC) than Australian-born in iduals. We therefore, modelled the consequences of different management strategies for chronic hepatitis B (CHB) in Asian-born adults aged > or = 35 years. A Markov model compared (1) enhanced surveillance for HCC alone (HCC surveillance), or (2) enhanced HCC surveillance coupled with CHB treatment (HCC prevention) to the current practice, of low CHB treatment uptake. Patients were stratified and managed according to risk categories, based upon hepatitis B virus (HBV) viral load and alanine aminotransferase (ALT) levels. We measured costs, health outcomes [cases of HCC and deaths averted, quality-adjusted life-years (QALYs) gained] and incremental cost-effectiveness ratios (ICERs). HCC surveillance would cost on average AU$8479 per person, compared to AU$2632 with current clinical practice and result in a gain of 0.014 QALYs (AU$401,516/QALY gained). A HCC prevention strategy would cost on average AU$14,600 per person, result in 0.923 QALYs gained (AU$12,956/QALY gained), reduce cases of cirrhosis by 52%, HCC diagnoses by 47% and CHB-related deaths by 56%, compared to current practice. HCC prevention appears to be a cost-effective public health strategy in at-risk populations in Australia and is preferable to HCC surveillance as a cancer control strategy.
Publisher: Oxford University Press (OUP)
Date: 11-07-2017
DOI: 10.1093/NDT/GFX216
Abstract: Decision-making regarding immunosuppression after transplantation relies on robust evidence on the benefits and harms of available drugs. We aimed to evaluate the reporting of adverse events (AEs) in trials of maintenance immunosuppression in kidney transplantation. We conducted a systematic review of published randomized controlled trials of maintenance immunosuppression following kidney transplantation in the Cochrane Kidney and Transplant Register (January 2003-December 2015). Appraisal against the 23-item harms extension of the Consolidated Standards of Reporting Trials statement was conducted. Of 233 trials, 163 (69%) reported at least one AE. Only 17 (10%) provided definitions or justified the AEs, 13 (8%) described methods and 27 (17%) measured severity. Forty AE types were reported, with gastrointestinal being the most common [116 (71%)]. The frequency of reporting did not reflect known drug side-effect profiles. For ex le, of 90 calcineurin inhibitor trials, only 22% reported tremors, 3% paresthesia and none anxiety, aggression or mood swings. Trials that reported at least one adverse effect were more likely to be industry funded {adjusted odds ratio [OR] 7.6 [95% confidence interval (CI) 3.4-17.1]}, multicenter [OR 5.9 (95% CI 1.7-18.7)] and with follow-up time <24 months [OR 3.7 (95% CI 1.4-10.2)]. AEs in kidney transplant immunosuppression trials appear to be selectively reported and may be unreliable for clinical decisions. Adherence to the Consolidated Standards of Reporting Trials harms extension should be mandatory to ensure transparent reporting of AEs that are important to patients and clinicians.
Publisher: Springer Science and Business Media LLC
Date: 21-07-2010
Publisher: Oxford University Press (OUP)
Date: 17-04-2009
DOI: 10.1093/NDT/GFP174
Abstract: Induction immunosuppression is perceived as an expensive therapy, so is often given only to select patients. This study evaluated the cost-effectiveness of antibody induction comparing interleukin-2 receptor antagonists (IL2Ra) to standard therapy with no induction or induction with polyclonal antibodies. A Markov model was developed to estimate costs and health outcomes [survival (life years saved, LYS) and quality-adjusted survival (QALYs)] for the alternative strategies. Outcome data were obtained from a meta-analysis of randomized trials and large-scale renal registries. IL2Ra offers improved survival of 0.21 LYS (2.5 months) and 1.42 QALYs compared with no induction, with a cost saving over 20 years of $79,302 per patient treated regardless of risk profile. The incremental benefits of IL2Ra compared with polyclonal antibody induction therapy were 0.35 LYS (4.3 months) and 0.20 QALYs, with an incremental cost of $5144 per patient. The incremental cost-effectiveness ratio (ICER) of IL2Ra compared to polyclonal induction was $14,803 per LYS and $25,928 per QALY. Sensitivity analyses showed that IL2Ra remained more effective and less expensive than no induction. When IL2Ra was compared to polyclonal induction, the model was sensitive to changes in the cost of induction and the probability of malignancy. Over the range of all other variables tested, IL2Ra was cost-effective compared to polyclonal induction. Adopting IL2Ra as induction immunosuppression for kidney transplant recipients improves survival and QALYs and is less costly than no induction. It also represents good value for money compared to polyclonal induction.
Publisher: CSIRO Publishing
Date: 2013
DOI: 10.1071/AH13081
Abstract: Objective To compare the costs of inpatient (usual care) with outpatient (intervention) care for cervical priming for induction of labour in women with healthy, low-risk pregnancies who are being induced for prolonged pregnancies or for social reasons. Methods Data from a randomised controlled trial at two hospitals in South Australia were matched with hospital financial data. A cost analysis comparing women randomised to inpatient care with those randomised to outpatient care was performed, with an additional analysis focusing on those who received the intervention. Results Overall, 48% of women randomised into the trial did not receive the intervention. Women randomised to outpatient care had an overall cost saving of $319 per woman (95% CI −$104 to $742) as compared with women randomised to usual care. When restricted to women who actually received the intervention, in-hospital cost savings of $433 (95% CI −$282 to $1148) were demonstrated in the outpatient group. However, these savings were partially offset by the cost of an outpatient priming clinic, reducing the overall cost savings to $156 per woman. Conclusions Overall cost savings were not statistically significant in women who were randomised to or received the intervention. However, the trend in cost savings favoured outpatient priming. What is known about the topic? Induction of labour is a common obstetric intervention. For women with low-risk, prolonged pregnancies who require cervical priming there has been increased interest in whether this period of waiting for the cervix to ‘ripen’ can be achieved at home. Outpatient priming has been reported to reduce hospital costs and improve maternal satisfaction. However, few studies have actually examined the cost of outpatient priming for induction of labour. What does this paper add? This is the first paper in Australia to both assess the full cost of outpatient cervical priming and to compare it with usual (inpatient) care. This is the first costing paper from a randomised controlled trial directly comparing inpatient and outpatient priming with prostaglandin E2. What are the implications for practitioners? For women with prolonged, low-risk pregnancies, a program of outpatient cervical priming can potentially reduce in-hospital costs and free up labour ward beds by avoiding an additional overnight hospitalisation.
Publisher: Elsevier BV
Date: 09-2013
DOI: 10.1016/J.IJCARD.2013.01.049
Abstract: Medication non-adherence poses a major barrier to reducing cardiovascular disease (CVD) burden globally, and is increasingly recognised as a socioeconomically determined problem. Strategies promoting CVD medication adherence appear of moderate effectiveness and cost-effectiveness. Potentially, 'one-size-fits-all' measures are ill-equipped to address heterogeneous adherence behaviour between social groups. This review aims to determine the effects of strategies to improve adherence to CVD-related medications in socioeconomically disadvantaged groups. Randomised/quasi-randomised controlled trials (1996-June 2012, English), testing strategies to increase adherence to CVD-related medications prescribed to adult patients who may experience health inequity (place of residence, occupation, education, or socioeconomic position) were reviewed. 772 abstracts were screened, 111 full-text articles retrieved, and 16 full-text articles reporting on 14 studies, involving 7739 patients (age range 41-66 years), were included. Methodological and clinical heterogeneity precluded quantitative data synthesis. Studies were thematically grouped by targeted outcomes underlying interventions and policies were classified using Michie et al.'s Behaviour Change Wheel. Contrasting with patient or physician ractice strategies, those simultaneously directed at patients and physicians ractices resulted in statistically significant improvements in relative adherence (16-169%). Comparative cost and cost-effectiveness analyses from three studies did not find cost-saving or cost-effective strategies. Unlike much current evidence in general populations, promising evidence exists about what strategies improve adherence in disadvantaged groups. These strategies were generally complex: simultaneously targeting patients and physicians addressing social, financial, and treatment-related adherence barriers and supported by broader guidelines, regulatory and communication-based policies. Given their complexity and potential resource implications, comprehensive process evaluations and cost and cost-effectiveness evidence are urgently needed.
Publisher: Springer Science and Business Media LLC
Date: 30-03-2022
DOI: 10.1007/S00467-022-05515-3
Abstract: Lower socioeconomic status (SES) is associated with lower academic achievement however, this relationship is understudied in children with chronic kidney disease (CKD). This study examined the relationship between SES and academic performance in children and adolescents with CKD. A total of 377 participants aged 6–18 years with CKD stages 1–5 ( n = 199), on dialysis ( n = 43) or with a kidney transplant ( n = 135) were recruited. Five SES measures and a composite SES index were examined for associations with parent-rated average or above average academic performance in numeracy and literacy using multivariable logistic regression. Participants’ median age was 12.6 years (IQR 8.9–15.5). Adjusted odds ratios (aOR) (95%CI) for better performance in numeracy and literacy, respectively, were 0.71 (0.44–1.15) and 0.75 (0.45–1.23) for children whose caregivers had lower educational attainment 0.46 (0.26–0.80) and 0.53 (0.30–0.93) for lower household income 0.52 (0.32–0.85) and 0.44 (0.26–0.73) for caregivers who were unemployed 0.68 (0.41–1.12) and 0.59 (0.35–1.00) for caregivers with poor self-rated financial status and 0.93 (0.53–1.64) and 1.00 (0.56–1.79) for caregivers who did not own their own home. Compared with the highest SES index quartile, the aORs for better performance by SES quartile in descending order were 1.24 (0.60–2.54), 0.76 (0.37–1.58), and 0.39 (0.18–0.86) for numeracy and 0.88 (0.41–1.85), 0.77 (0.35–1.66), and 0.32 (0.14–0.72) for literacy. No interactions were identified between SES and CKD stage, child age, or gender. Across all CKD stages, children from lower SES families are less likely to perform well in literacy and numeracy than those from higher SES households. A higher resolution version of the Graphical abstract is available as Supplementary information
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 28-02-2020
DOI: 10.2215/CJN.12341019
Abstract: The dietary self-management of CKD is challenging. Telehealth interventions may provide an effective delivery method to facilitate sustained dietary change. This pilot, randomized, controlled trial evaluated secondary and exploratory outcomes after a dietitian-led telehealth coaching intervention to improve diet quality in people with stage 3–4 CKD. The intervention group received phone calls every 2 weeks for 3 months (with concurrent, tailored text messages for 3 months), followed by 3 months of tailored text messages without telephone coaching, to encourage a diet consistent with CKD guidelines. The control group received usual care for 3 months, followed by nontailored, educational text messages for 3 months. Eighty participants (64% male), aged 62±12 years, were randomized to the intervention or control group. Telehealth coaching was safe, with no adverse events or changes to serum biochemistry at any time point. At 3 months, the telehealth intervention, compared with the control, had no detectable effect on overall diet quality on the Alternative Health Eating Index (3.2 points, 95% confidence interval, −1.3 to 7.7), nor at 6 months (0.5 points, 95% confidence interval, −4.6 to 5.5). There was no change in clinic BP at any time point in any group. There were significant improvements in several exploratory diet and clinical outcomes, including core food group consumption, vegetable servings, fiber intake, and body weight. Telehealth coaching was safe, but appeared to have no effect on the Alternative Healthy Eating Index or clinic BP. There were clinically significant changes in several exploratory diet and clinical outcomes, which require further investigation. Evaluation of In idualized Telehealth Intensive Coaching to Promote Healthy Eating and Lifestyle in CKD (ENTICE-CKD), ACTRN12616001212448.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 22-02-2018
DOI: 10.2215/CJN.09650917
Abstract: Poor cognition can affect educational attainment, but the extent of neurocognitive impairment in children with CKD is not well understood. This systematic review assessed global and domain-specific cognition and academic skills in children with CKD and whether these outcomes varied with CKD stage. Electronic databases were searched for observational studies of children with CKD ages 21 years old or younger that assessed neurocognitive or educational outcomes. Risk of bias was assessed using a modified Newcastle–Ottawa scale. We used random effects models and expressed the estimates as mean differences with 95% confidence intervals stratified by CKD stage. Thirty-four studies (25 cross-sectional, n =2095 nine cohort, n =991) were included. The overall risk of bias was high because of selection and measurement biases. The global cognition (full-scale intelligence quotient) of children with CKD was classified as low average. Compared with the general population, the mean differences (95% confidence intervals) in full-scale intelligence quotient were −10.5 (95% confidence interval, −13.2 to −7.72 all CKD stages, n =758), −9.39 (95% confidence interval, −12.6 to −6.18 mild to moderate stage CKD, n =582), −16.2 (95% confidence interval, −33.2 to 0.86 dialysis, n =23), and −11.2 (95% confidence interval, −17.8 to −4.50 transplant, n =153). Direct comparisons showed that children with mild to moderate stage CKD and kidney transplants scored 11.2 (95% confidence interval, 2.98 to 19.4) and 10.1 (95% confidence interval, −1.81 to 22.0) full-scale intelligence quotient points higher than children on dialysis. Children with CKD also had lower scores than the general population in executive function and memory (verbal and visual) domains. Compared with children without CKD, the mean differences in academic skills ( n =518) ranged from −15.7 to −1.22 for mathematics, from −9.04 to −0.17 for reading, and from −14.2 to 2.53 for spelling. Children with CKD may have low-average cognition compared with the general population, with mild deficits observed across academic skills, executive function, and visual and verbal memory. Limited evidence suggests that children on dialysis may be at greatest risk compared with children with mild to moderate stage CKD and transplant recipients.
Publisher: BMJ
Date: 2012
Publisher: Springer Science and Business Media LLC
Date: 08-04-2022
DOI: 10.1186/S43058-022-00291-5
Abstract: Physical inactivity is a leading risk factor for chronic disease. Brief physical activity counselling delivered within healthcare systems has been shown to increase physical activity levels however, implementation efforts have mostly targeted primary healthcare and uptake has been sub-optimal. The Brief Physical Activity Counselling by Physiotherapists (BEHAVIOUR) trial aims to address this evidence-practice gap by evaluating (i) the effectiveness of a multi-faceted implementation strategy, relative to usual practice for improving the proportion of patients receiving brief physical activity counselling as part of their routine hospital-based physiotherapy care and (ii) effectiveness of brief physical activity counselling embedded in routine physiotherapy care, relative to routine physiotherapy care, at improving physical activity levels among patients receiving physiotherapy care. Effectiveness-implementation hybrid type II cluster randomised controlled trial with embedded economic evaluation, qualitative study and culturally adapted patient-level outcome measures. The trial will be conducted across five hospitals in a local health district in Sydney, Australia, with a lower socioeconomic and culturally erse population. The evidence-based intervention is brief physical activity counselling informed by the 5As counselling model and behavioural theory, embedded into routine physiotherapy care. The multi-faceted strategy to support the implementation of the counselling intervention was developed with key stakeholders guided by the Consolidated Framework for Implementation Research and the Capabilities, Opportunities, Motivation-Behaviour (COM-B) theoretical model, and consists of clinician education and training, creating a learning collaborative, tailored strategies to address community referral barriers, team facilitation, and audit and feedback. Thirty teams of physiotherapists will be randomised to receive the multi-faceted implementation strategy immediately or after a 9-month delay. Each physiotherapy team will recruit an average of 10 patients ( n =300) to collect effectiveness outcomes at baseline and 6 months. The primary effectiveness outcome is self-reported planned physical activity using the Incidental and Planned Exercise Questionnaire, and the primary implementation outcome is reach (proportion of eligible new physiotherapy patients who receive brief physical activity counselling). Secondary effectiveness and implementation outcomes will also be collected. This project focuses on physiotherapists as health professionals with the requisite skills and patterns of practice to tackle the increasing burden of chronic disease in a high-risk population. ANZCTR, ACTRN12621000194864 . Registered on 23 February 2021.
Publisher: Springer Science and Business Media LLC
Date: 26-04-2022
DOI: 10.1186/S12877-022-03050-2
Abstract: Falls are a significant public health issue. There is strong evidence that exercise can prevent falls and the most effective programs are those that primarily involve balance and functional exercises, however uptake of such programs is low. Exercise prescribed during home visits by health professionals can prevent falls however this strategy would be costly to deliver at scale. We developed a new approach to teach home exercise through group-based workshops delivered by physiotherapists. The primary aim was to determine the effect of this approach on the rate of falls among older community-dwelling people over 12 months. Secondary outcomes included the proportion of people falling, fear of falling, physical activity, lower limb strength, balance and quality of life. A randomised controlled trial was conducted among community-dwelling people aged ≥65 in New South Wales, Australia. Participants were randomised to either the intervention group (exercise targeting balance and lower limb strength) or control group (exercise targeting upper limb strength). A total of 617 participants (mean age 73 years, + SD 6, 64% female) were randomly assigned to the intervention group ( n = 307) or control group ( n = 310). There was no significant between-group difference in the rate of falls (IRR 0.91, 95% CI 0.64 to 1.29, n = 579, p = 0.604) or the number of participants reporting one or more falls (IRR 0.99, 95% CI 0.76 to 1.29, n = 579, p = 0.946) during 12 month follow-up. A significant improvement in the intervention group compared to control group was found for fear of falling at 3, 6 and 12 months (mean difference 0.50, 95% CI 0.2 to 0.8, p = 0.004 0.39, 95% CI 0.001 to 0.8, p = 0.049 0.46, 95% CI 0.006 to 0.9, p = 0.047, respectively), and gait speed at 3 months (mean difference 0.09 s, 95% CI 0.003 to 0.19, p = 0.043). No statistically significant between-group differences were detected for the other secondary outcomes. There was no significant intervention impact on the rate of falls, but the program significantly reduced fear of falling and improved gait speed. Other exercise delivery approaches are needed to ensure an adequate intensity of balance and strength challenge and dose of exercise to prevent falls.
Publisher: SAGE Publications
Date: 20-11-2022
DOI: 10.1177/02692155221138920
Abstract: To investigate the trial-based cost-effectiveness of the addition of a tailored digitally enabled exercise intervention to usual care shown to be clinically effective in improving mobility in the Activity and MObility UsiNg Technology (AMOUNT) rehabilitation trial compared to usual care alone. Economic evaluation alongside a pragmatic randomized controlled trial. 300 people receiving inpatient aged and neurological rehabilitation were randomized to the intervention ( n = 149) or usual care control group ( n = 151). Incremental cost effectiveness ratios were calculated for the additional costs per additional person demonstrating a meaningful improvement in mobility (3-point in Short Physical Performance Battery) and quality-adjusted life years gained at 6 months (primary analysis). The joint probability distribution of costs and outcomes was examined using bootstrapping. The mean cost saving for the intervention group at 6 months was AU$2286 (95% Bootstrapped cost CI: −$11,190 to $6410) per participant 68% and 67% of bootstraps showed the intervention to be dominant (i.e. more effective and cost saving) for mobility and quality-adjusted life years, respectively. The probability of the intervention being cost-effective considering a willingness to pay threshold of AU$50,000 per additional person with a meaningful improvement in mobility or quality-adjusted life year gained was 93% and 77%, respectively. The AMOUNT intervention had a high probability of being cost-effective if decision makers are willing to pay AU$50,000 per meaningful improvement in mobility or per quality-adjusted life year gained, and a moderate probability of being cost-saving and effective considering both outcomes at 6 months post randomization.
Publisher: Springer Science and Business Media LLC
Date: 02-10-2021
DOI: 10.1186/S13104-021-05794-3
Abstract: To identify sociodemographic factors and health conditions associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults. Participants were recruited via investigator networks and an online panel provider with an established nationwide panel of Aboriginal and Torres Strait Islander adults. Those interested were invited to complete a survey that included an assessment of wellbeing using a visual analogue scale. Data was collected from October–November 2019 and August–September 2020. Exploratory analyses were conducted to ascertain factors associated with self-rated wellbeing for Aboriginal and Torres Strait Islander adults. Having more than enough money to last until next pay day, full-time employment, completion of grade 12, having a partner, and living with others were significantly associated with higher wellbeing among Aboriginal and Torres Strait Islander adults. A self-reported history of depression, anxiety, other mental health conditions, heart disease, or disability were associated with lower self-rated wellbeing scores. Our findings indicate a need for further investigation among these socioeconomic and patient groups to identify how to improve and support the wellbeing of Aboriginal and Torres Strait Islander adults.
Publisher: MDPI AG
Date: 08-06-2021
Abstract: Aboriginal and Torres Strait Islander people experience a greater range of health and social disadvantages compared to other Australians. Wellbeing is a culturally-bound construct, and to date, a national evidence base around the components of wellbeing for Aboriginal and Torres Strait Islander people is lacking. Understanding and measurement of wellbeing for this population is critical in achieving health equity. This paper aims to identify and describe the foundations of wellbeing for Aboriginal and Torres Strait Islander adults. This national qualitative study was underpinned by an Indigenist research approach which privileges the voices of Aboriginal and Torres Strait Islander people. Aboriginal and Torres Strait Islander adults were purposively recruited from around Australia between September 2017 and September 2018 to participate in Yarning Circles, led by Aboriginal and Torres Strait Islander researchers. Yarning Circles were audio recorded, transcribed and analyzed. A Collaborative Yarning Methodology was used, which incorporated reflexive thematic analysis to identify and describe the foundations of wellbeing reported by participants. A total of 359 Aboriginal and Torres Strait Islander adults participated. Our analysis revealed five foundations of wellbeing: belonging and connection holistic health purpose and control dignity and respect and basic needs. These foundations were deeply interwoven by three interconnected aspects of Aboriginal and Torres Strait Islander life: family, community and culture. The findings of this study will substantially aid our efforts to develop a new wellbeing measure for Aboriginal and Torres Strait Islander adults. The iterative Indigenist methods used in this study provide a robust research methodology for conducting large-scale, nationally-relevant qualitative research with Aboriginal and Torres Strait Islander people. Policies and practices that are informed by our results have the potential to address outcomes that are meaningful for Aboriginal and Torres Strait Islander people.
Publisher: BMJ
Date: 04-2018
Publisher: Oxford University Press (OUP)
Date: 12-2012
Abstract: S le adequacy is an important aspect of overall fine-needle aspiration cytology (FNAC) performance. FNAC effectiveness is augmented by an increasing number of needle passes, but increased needle passes are associated with higher costs and greater risk of adverse events. The objective of this study was to compare the impact of several different s ling policies on FNAC effectiveness and adverse event rates using discrete event simulation. We compared 8 different s ling policies in 12 different s ling environments. All s ling policies were effective when the per-pass accuracy is high (& %). Rapid on-site evaluation (ROSE) improves FNAC effectiveness when the per-pass adequacy rate is low. ROSE is unlikely to be cost-effective in s ling environments in which the per-pass adequacy is high. Alternative ROSE assessors (eg, cytotechnologists) may be a cost-effective alternative to pathologists when the per-pass adequacy rate is moderate (60%–80%) or when the number of needle passes is limited.
Publisher: Wiley
Date: 23-02-2012
DOI: 10.1111/J.1440-1797.2011.01549.X
Abstract: Despite an increased risk of cancer post transplant, little is known about the knowledge, beliefs of and attitudes to cancer and its prevention among kidney transplant recipients. This study aims to explore these beliefs and attitudes, to better understand patient motives and potential barriers to early detection of cancer. Semi-structured interviews were conducted with 14 kidney and eight kidney-pancreas transplant recipients based at a single transplant centre in Sydney, Australia, between October 2009 and February 2010. Thematic data analysis identified four major themes: (1) skin cancer-focused: participants were generally only aware about their increased risk of skin cancer and available prevention strategies for that cancer alone (2) limited awareness: participants knew little about their excess risk for non-skin cancers and possible preventative and screening strategies (3) fear of cancer: cancer fears were heightened by prior experiences some felt vulnerable to cancer and perceived that cancer outcomes were worse than kidney disease and (4) prioritizing present health issues: participants believed cancer was not imminent and had limited capacity to absorb information about long-term risks, particularly as current health concerns appeared pressing and important. Awareness of increased cancer risk and cancer screening among kidney transplant recipients is focused narrowly on skin cancer, with limited awareness for other cancers. Recipients prioritized current health issues rather than future risks to health such as cancer. Transplant care providers should provide evidence-based information on cancer risk and screening, being sensitive to the timing and needs of the patient. Improved knowledge may empower patients to minimize their risk of cancer by participating in screening and cancer prevention programmes.
Publisher: Wiley
Date: 17-01-2022
DOI: 10.1111/AJR.12822
Publisher: BMJ
Date: 23-01-2013
DOI: 10.1136/BMJ.F158
Publisher: Oxford University Press (OUP)
Date: 27-06-2011
DOI: 10.1093/NDT/GFQ376
Publisher: Springer Science and Business Media LLC
Date: 19-04-2021
DOI: 10.1186/S12882-021-02344-8
Abstract: End stage kidney disease (ESKD) is associated with many losses, subsequently impacting mental wellbeing. Few studies have investigated the efficacy of psychosocial interventions for people with ESKD and none exist for Indigenous people, a population in which the ESKD burden is especially high. This three-arm, waitlist, single-blind randomised controlled trial examined efficacy of the Stay Strong App in improving psychological distress (Kessler distress scale K10), depressive symptoms (adapted Patient Health Questionnaire PHQ-9), quality of life (EuroQoL EQ. 5D) and dialysis adherence among Indigenous Australians undergoing haemodialysis in central and northern Australia (Alice Springs and Darwin), with follow up over two 3-month periods. Effects of immediate AIMhi Stay Strong App treatment were compared with those from a contact control app (The Hep B Story) and treatment as usual (TAU). Control conditions received the Stay Strong intervention after 3 months. Primary analyses of the full s le ( N = 156) showed statistically significant decreases in K10 and PHQ-9 scores at 3 months for the Hep B Story but not for the Stay Strong app or TAU. Restricting the s le to those with moderate to severe symptoms of distress or depression (K10 =25 or PHQ-9 =10) showed significant decreases in K10 and PHQ-9 scores for both Stay Strong and Hep B Story. No significant differences were observed for the EQ-5D or dialysis attendance. Findings suggest that talking to people about their wellbeing and providing information relevant to kidney health using culturally adapted, locally relevant apps improve the wellbeing of people on dialysis. Further research is required to replicate these findings and identify active intervention components. ACTRN12617000249358 17/02/2017.
Publisher: Wiley
Date: 24-04-2019
DOI: 10.1111/NEP.13445
Abstract: Assessing the impact of interventions on the patient experience requires measures that are plausibly responsive to change. In a community cohort of people with and without chronic kidney disease (CKD) markers at baseline, we aimed to evaluate change in commonly used measures of quality of life (QOL) over the passage of 5 years. Included were 6400 participants in the Australian Diabetes, Obesity and Lifestyle (AusDiab) surveys with baseline and 5-year CKD and QOL measures. Changes in SF-6D utility, and the Medical Outcomes Study 36-Item Short Form (SF-36) physical (PCS) and mental (MCS) component summary scores, were evaluated with regression analyses according to the baseline presence of reduced estimated glomerular filtration rate (eGFR) (CKD-Epidemiology Collaboration eGFR ≤60 m/min per 1.73 m At baseline, eGFR was reduced in 2.4% of participants and 5.1% had albuminuria. Participants with reduced eGFR had a lower SF-6D and PCS, and those with albuminuria a lower PCS, compared with those without, but the differences were explained by known confounders. MCS scores were not affected by the presence of reduced eGFR or albuminuria. Over 5 years all groups exhibited stable SF-6D and MCS scores but declining unadjusted PCS scores. PCS decline was greater for those with reduced eGFR, and remained significant after adjustment (-2.7 (-4.1 to -1.3) vs. -0.8 (-1.1 to -0.6, P < 0.01). Analyses according to CKD stages were essentially unchanged. Utility and mental QOL appears stable over 5 years, unaffected by time or markers of CKD health. Physical QOL appeared to deteriorate with time, especially for those with CKD, making it a more likely candidate assessment measure for intervention and health service evaluations.
Publisher: Wiley
Date: 15-05-2016
DOI: 10.1111/HDI.12424
Publisher: BMJ
Date: 15-04-2015
Publisher: Elsevier BV
Date: 11-2008
DOI: 10.1053/J.AJKD.2008.06.015
Abstract: Breast cancer screening is recommended for women 50 years and older in most developed countries. Women on dialysis therapy have a risk of acquiring breast cancer similar to that for other women, but a greater all-cause mortality rate because of mortality from other competing causes. It is uncertain whether routine screening is cost-effective in women on dialysis therapy. In this study, we determine the costs and health outcomes of annual mammographic breast cancer screening in women on dialysis therapy. We performed a cost-effectiveness analysis. Sensitivity and scenario analyses were performed to assess uncertainties in the model's parameter estimates. BASE CASE: A cohort (n = 1,000) of women on dialysis therapy aged 50 to 69 years in Australia. MODEL, PERSPECTIVE, AND TIME FRAME: A deterministic Markov model was developed from the perspective of a health care payer. Patients were followed up over their life time. We compared a cohort of women who underwent annual mammography with a cohort that did not. Life-years saved (LYS), costs, and incremental cost-effectiveness ratio (ICER). Average costs for a program of annual screening for a woman on dialysis therapy were $4,805 over 30 years. Incremental costs of screening were $403, and benefits were 0.0037 LYS. Five breast cancer deaths occurred in the screened arm and 6 breast cancer deaths occurred in the unscreened arm, a difference of 1 breast cancer averted by screening, with an estimated ICER of $109,852/LYS. The absolute reduction in breast cancer mortality was 0.1%, with a net gain in life expectancy of 1.3 days. The ICER was strongly dependent on age, with the most favorable ICER approximately $100,000/LYS at age 45 years. Costs and clinical data were obtained from the nonindigenous Australian population and may not be generalizable to African Americans on dialysis therapy and indigenous populations from other countries. Using the most optimistic assumptions, survival gains expected from screening for breast cancer in women on dialysis therapy are very small. Annual population breast cancer screening should not be recommended for all women on dialysis therapy, but should be an in idual decision between the patient and health care provider.
Publisher: Wiley
Date: 17-03-2021
DOI: 10.1111/HEX.13230
Abstract: Evaluations of health interventions for Indigenous peoples rarely report outcomes that reflect participant and community perspectives of their experiences. Inclusion of such data may provide a fuller picture of the impact of health programmes and improve the usefulness of evaluation assessments. To describe stakeholder perspectives and experiences of the implementation and impact of Indigenous health programmes. We conducted a systematic review of qualitative studies evaluating complex health interventions designed for Indigenous communities in high‐income countries. We searched 6 electronic databases (through to January 2020): MEDLINE, PreMEDLINE, Embase, PsycINFO, EconLit and CINAHL and hand‐searched reference lists of relevant articles. From 28 studies involving 677 stakeholders (mostly clinical staff and participants), six main themes were identified: enabling engagement, regaining control of health, improving social health and belonging, preserving community and culture, cultivating hope for a better life, and threats to long‐term programme viability. The prominence of social, emotional and spiritual well‐being as important aspects of the health journey for participants in this review highlights the need to reframe evaluations of health programmes implemented in Indigenous communities away from assessments that focus on commonly used biomedical measures. Evaluators, in consultation with the community, should consistently assess the capacity of health professionals to meet community needs and expectations throughout the life of the programme. Evaluations that include qualitative data on participant and community‐level outcomes can improve decision‐makers' understanding of the impact that health programmes have on communities. This paper is a review of evaluation studies and did not involve patients or the public.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2015
Publisher: Elsevier BV
Date: 12-2011
Publisher: Springer Science and Business Media LLC
Date: 17-11-2020
DOI: 10.1186/S12889-020-09821-Z
Abstract: Understandings of health and wellbeing are culturally bound. Many Aboriginal and Torres Strait Islander people perceive wellbeing and quality of life (QOL) differently from the Western biomedical models of health underpinning existing QOL instruments. Any instrument to measure the wellbeing of Aboriginal and Torres Strait Islander people should be culturally appropriate and safe, include relevant dimensions, and be informed by their own values and preferences. Existing QOL instruments do not meet these standards. This study will generate a new preference-based wellbeing measure, WM2Adults, for Aboriginal and Torres Strait Islander adults, underpinned by their values and preferences. A mixed methods approach will be used we will employ decolonising methodologies, privilege Aboriginal and Torres Strait Islander voices and perspectives, and adopt a strengths-based approach rather than a deficit lens. Yarning Circles will be conducted with Aboriginal and Torres Strait Islander people across Australia. A candidate item pool will be developed from these data, on which psychometric analysis and validity testing will be undertaken to develop a descriptive system. Following finalisation of the descriptive system, wellbeing states will be valued using a quantitative preference-based approach (best-worst scaling) with a erse s le of Aboriginal and Torres Strait Islander adults ( n = 1000). A multinomial (conditional) logit framework will be used to analyse responses and generate a scoring algorithm for the new preference-based WM2Adults measure. The new wellbeing measure will have wide applicability in assessing the effectiveness and cost-effectiveness of new programs and services for Aboriginal and Torres Strait Islander people. Results will be disseminated through journals, conferences and policy forums, and will be shared with Aboriginal and Torres Strait Islander communities, organisations and research participants.
Publisher: Oxford University Press (OUP)
Date: 06-2022
Abstract: globally, falls and fall-related injuries are the leading cause of injury-related morbidity and mortality in older people. In our ageing society healthcare costs are increasing, therefore programmes that reduce falls and are considered value for money are needed. to complete an economic evaluation of an e-Health balance exercise programme that reduced falls and injurious falls in community-dwelling older people compared to usual care from a health and community-care funder perspective. a within-trial economic evaluation of an assessor-blinded randomised controlled trial with 2 years of follow-up. StandingTall was delivered via tablet-computer at home to older community-dwelling people in Sydney, Australia. five hundred and three in iduals aged 70+ years who were independent in activities of daily living, without cognitive impairment, progressive neurological disease or any other unstable or acute medical condition precluding exercise. cost-effectiveness was measured as the incremental cost per fall and per injurious fall prevented. Cost-utility was measured as the incremental cost per quality-adjusted life year (QALY) gained. the total average cost per patient for programme delivery and care resource cost was $8,321 (standard deviation [SD] 18,958) for intervention participants and $6,829 (SD 15,019) for control participants. The incremental cost per fall prevented was $4,785 and per injurious fall prevented was $6,585. The incremental cost per QALY gained was $58,039 (EQ5D-5L) and $110,698 (AQoL-6D). this evaluation found that StandingTall has the potential to be cost-effective in specific subpopulations of older people, but not necessarily the whole older population. ACTRN12615000138583.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 30-04-2019
Abstract: Colorectal cancer screening using fecal immunochemical testing (FIT) is recommended for patients with CKD, whose risk of developing and dying from this malignancy is at least 1.5 times higher than that of the sex- and age-matched general population. However, FIT accuracy in this setting is unknown and is likely to be affected by occult gastrointestinal bleeding from dysfunctional platelets and increased bleeding sensitivity to aspirin. In a large, multinational study, the authors found that FIT appears to be an accurate screening test for patients with CKD, but the risk of major complications from work-up colonoscopies (1.5%) is high compared with this risk in the general population. These findings provide useful estimates of harms and test accuracies to inform colorectal cancer screening decisions across the full spectrum of CKD. In patients with CKD, the risk of developing colorectal cancer is high and outcomes are poor. Screening using fecal immunochemical testing (FIT) is effective in reducing mortality from colorectal cancer, but performance characteristics of FIT in CKD are unknown. To determine the detection rates and performance characteristics of FIT for advanced colorectal neoplasia (ACN) in patients with CKD, we used FIT to prospectively screen patients aged 35–74 years with CKD (stages 3–5 CKD, dialysis, and renal transplant) from 11 sites in Australia, New Zealand, Canada, and Spain. All participants received clinical follow-up at 2 years. We used a two-step reference standard approach to estimate disease status. Overall, 369 out of 1706 patients who completed FIT (21.6%) tested positive 323 (87.5%) underwent colonoscopies. A total of 1553 (91.0%) completed follow-up 82 (4.8%) had died and 71 (4.2%) were lost. The detection rate of ACN using FIT was 6.0% (5.6%, 7.4%, and 5.6% for stages 3–5 CKD, dialysis, and transplant). Sensitivity, specificity, and positive and negative predictive values of FIT for ACN were 0.90, 0.83, 0.30, and 0.99, respectively. Of participants who underwent colonoscopy, five (1.5%) experienced major colonoscopy-related complications, including bowel perforation and major bleeding. FIT appears to be an accurate screening test for patients with CKD, such that a negative test may rule out the diagnosis of colorectal cancer within 2 years. However, the risk of major complications from work-up colonoscopy are at least ten-fold higher than in the general population.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2018
Publisher: AMPCo
Date: 02-2011
Publisher: Springer Science and Business Media LLC
Date: 26-07-2021
DOI: 10.1186/S12889-021-11496-Z
Abstract: Oropharyngeal squamous cell carcinoma (OPSCC) is associated with high mortality. Human papillomavirus (HPV) infection is a significant risk factor for OPSCC. Utilities are fundamental values representing the strength of in iduals’ preferences for specific health-related outcomes. Our study aim was to work in partnership with Indigenous communities in South Australia to develop, pilot test and estimate utility scores for health states related to HPV, HPV vaccination, precursor OPSCC and its treatment, and early stage OPSCC among Indigenous Australians. Development and pilot testing of hypothetical HPV and OPSCC health states, specifically through the lens of being Indigenous Australian, was conducted with an Indigenous Reference Group. Six health states were decided upon, with utility scores calculated using a two-stage standard gamble approach among a large convenience s le of Indigenous Australians aged 18+ years residing in South Australia. The rank, percentage of perfect health and utility score of each health state was summarised using means, and medians at 12 months and lifetime duration. Potential differences by age, sex and residential location were assessed using the Wilcox Rank Sum test. Data from 1011 participants was obtained. The mean utility scores decreased with increasing severity of health states, ranging from 0.91–0.92 in ‘screened, cytology normal, HPV vaccination’ and ‘screened, HPV positive, endoscopy normal’, to less than 0.90 (ranging from 0.87–0.88) in lower grade conditions (oral warts and oral intraepithelial neoplasia) and less than 0.80 (ranging from 0.75–0.79) in ‘early stage throat cancer’. Higher utility scores were observed for ‘screened, cytology normal and HPV vaccination’ among younger participants (18–40 years), for ‘early stage invasive throat cancer’ among females, and for ‘oral intraepithelial neoplasia’ and ‘early stage invasive throat cancer’ among metropolitan-dwelling participants. Among a large s le of Indigenous Australians, utility for oral HPV infection and OPSCC decreased with severity of health states. Older participants, as well as males and those residing in non-metropolitan locations, had decreased utility for high-grade cytology and early invasive cancer states. Our findings are an important contribution to cost-utility and disease prevention strategies that seek to inform policies around reducing HPV infection and OPSCC among all Australians.
Publisher: Wiley
Date: 13-05-2016
DOI: 10.1002/CNCY.21730
Abstract: In a cytology-based screening program intended to prevent anal cancer, the anal transformation zone (TZ) should be adequately s led because it is the site most susceptible to the development of the cancer precursor, high-grade squamous intraepithelial lesion (HSIL). An adequate TZ component is defined as comprising at least 10 rectal columnar or squamous metaplastic cells. In the current study, the authors examined whether the presence of a TZ component in anal cytology correlated with the detection of histological HSIL. In a natural history study of anal human papillomavirus infection in homosexual men, all participants underwent liquid-based cytology and high-resolution anoscopy (HRA) with or without biopsy at each visit. True-negative cytology (negative cytology with non-HSIL biopsy or negative HRA), false-negative cytology (negative cytology with HSIL biopsy), and true-positive cytology (abnormal cytology with HSIL biopsy) were compared with regard to the presence or absence of a TZ component. Of 617 participants, baseline results included 155 true-positive results, 191 true-negative results, and 31 false-negative results. The absence of an adequate TZ component was found to be significantly higher for false-negative (32.3%) than for either true-positive (11.0% P = .0034) or true-negative (13.1% P = .0089) results. Significantly more false-negative cases lacked a TZ component compared with either true-positive or true-negative cases. TZ cells may be an important indicator of s le quality for anal cytology because, unlike cervical s ling, the anal canal is not visualized during cytology s ling. Cancer Cytopathol 2016 :596-601. © 2016 American Cancer Society.
Publisher: CMA Joule Inc.
Date: 06-02-2012
DOI: 10.1503/CMAJ.111355
Publisher: BMJ
Date: 09-02-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 19-10-2018
DOI: 10.2215/CJN.06830617
Abstract: Improved knowledge about factors that influence patient choices when considering dialysis modality could facilitate health care interventions to increase rates of home dialysis. We aimed to quantify the attributes of dialysis care and the tradeoffs that patients consider when making decisions about dialysis modalities. We conducted a prospective, discrete choice experiment survey with random parameter logit analysis to quantify preferences and tradeoffs for attributes of dialysis treatment in 143 adult patients with CKD expected to require RRT within 12 months (predialysis). The attributes included schedule flexibility, patient out of pocket costs, subsidized transport services, level of nursing support, life expectancy, dialysis training time, wellbeing on dialysis, and dialysis schedule (frequency and duration). We reported outcomes using β -coefficients with corresponding odds ratios and 95% confidence intervals for choosing home-based dialysis (peritoneal dialysis or hemodialysis) compared with facility hemodialysis. Home-based therapies were significantly preferred with the following attributes: longer survival (odds ratio per year, 1.63 95% confidence interval, 1.25 to 2.12), increased treatment flexibility (odds ratio, 9.22 95% confidence interval, 2.71 to 31.3), improved wellbeing (odds ratio, 210 95% confidence interval, 15 to 2489), and more nursing support (odds ratio, 87.3 95% confidence interval, 3.8 to 2014). Respondents were willing to accept additional out of pocket costs of approximately New Zealand $400 (United States $271) per month (95% confidence interval, New Zealand $333 to $465) to receive increased nursing support. Patients were willing to accept out of pocket costs of New Zealand $223 (United States $151) per month (95% confidence interval, New Zealand $195 to $251) for more treatment flexibility. Patients preferred home dialysis over facility-based care when increased nursing support was available and when longer survival, wellbeing, and flexibility were expected. Sociodemographics, such as age, ethnicity, and income, influenced patient choice.
Publisher: Elsevier BV
Date: 08-2012
DOI: 10.1053/J.AJKD.2012.02.339
Abstract: Immunosuppression is associated with a number of adverse outcomes, but typically it is the physician, not the patient, who decides on the drug regimen. The perspective of the patient in clinical decision making is increasingly recognized in other settings, but the perspectives of kidney transplant recipients are largely unknown. The aim of this study was to elicit patient perspectives and priorities for outcomes after transplant and the reasons underpinning these priorities. Outcome identification and ranking were undertaken using a focus/nominal group technique. Adult kidney transplant recipients, purposively s led from 3 transplant centers, participated in 1 of 8 nominal groups. Each group (6-10 participants) listed and ranked outcomes relevant to immunosuppressant medications. 57 participants identified 47 outcomes relevant to immunosuppression after transplant surgery. Transplant survival consistently was ranked more highly than any other outcome, followed by damage to other organs, survival, and cancer. Only 12% of participants ranked their own survival as more important than transplant survival. In contrast, the relative importance of side effects differed among participants. Themes underpinning priorities were concern for fatal and serious events relevance to life circumstance acceptance, trivialization, and tolerance and future outlook. Participants described a willingness to tolerate side effects, dependent on personal relevance and ability to manage the side effect. Transplant survival appears to be more important than life itself to kidney transplant recipients, suggesting that they may be willing to tolerate a higher level of immunosuppression than is assumed by clinicians and researchers.
Publisher: Springer Science and Business Media LLC
Date: 30-07-2014
Publisher: Public Library of Science (PLoS)
Date: 11-09-2012
Start Date: 2009
End Date: 2013
Funder: Australian Research Council
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Funder: National Health and Medical Research Council
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Funder: Australian Research Council
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Funder: National Health and Medical Research Council
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Funder: National Health and Medical Research Council
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Funder: National Health and Medical Research Council
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Funder: National Health and Medical Research Council
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Funder: National Health and Medical Research Council
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Funder: National Health and Medical Research Council
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Funder: National Health and Medical Research Council
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Funder: National Health and Medical Research Council
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Funder: National Health and Medical Research Council
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Funder: National Health and Medical Research Council
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