Health Economics and Indigenous Health: measuring value beyond health outcomes

Australia has decades of public policy experience attempting to overcome the disparities in health outcomes facing Aboriginal and Torres Strait Islander (Indigenous) Australians. Significant resources have accompanied these policy initiatives, however, Indigenous Australians continue to bear a heavier burden of death, disease, disability and economic hardship than other Australians. Despite the policy experience of Australia and widespread support for initiatives to overcome Indigenous disadvantage, there is little consensus on the best means to actually do so. Working to ensure that available resources are used in their most effective way possible is vital to improving the health of Australia’s Indigenous populations. At its broadest level, health economics is the study of the choices made in the allocation of scarce resources to improve the health status of populations and service delivery. Notwithstanding the political, moral and economic importance of the issue, there remains limited health economic research in the field of Indigenous health nor is there a developed evidence base to provide guidance to policy-makers looking to invest in cost-effective interventions. Further, health economic methods have been criticised as potentially inappropriate for the area of Indigenous health. Current methods for economic evaluation tend to adopt a reductionist approach based on a cost per health outcome paradigm and are potentially insensitive to the outcomes and processes that Indigenous people see to be of value to their health and health care on three broad and related levels. First, Indigenous conceptions of health have been shown to differ from the biomedical notions which tend to underlie the reductionist approach of health economic evaluations. Second, a central tenet of Indigenous health care is community ownership and control of healthcare services. As such there is value associated with how well services achieve engagement with communities which may also be missed through a reductionist health economic approach. Third, social determinants of health have also been demonstrated to be particularly important to the health outcomes of Indigenous Australians but again have tended to lie outside the domain of traditional economic evaluation methods. Potentially because of these and other difficulties, resource allocation decisions in the field of Indigenous health have been made without a strong economic evidence-base and have instead seemingly relied on rights-based arguments promoting investment based on the sizeable need that these communities face. While there is no denying the stark disadvantage facing Australia’s Indigenous populations, such rights-based arguments provide little guidance on how much to invest or on trade-offs between different policy options or individual service components. Further, the weight attributed to such arguments has tended to vary according to the prevailing political climate. Health economic approaches on the other hand, can provide evidence based on value that can transcend politics and lay the foundation for rational priority-setting that maximises the health of target populations. Ignoring the realities of resource scarcity in the sector will not allow policy interventions to maximise the health outcomes for Australia’s Indigenous communities. Health economic methods such as discrete choice experiments (DCEs) and contingent valuation studies have been used to value factors outside of traditional economic evaluations in other fields yet have been largely untested in Australian Indigenous populations. Such techniques potentially represent a direct means through which to incorporate Indigenous values and preferences into the evaluation and design of health programs and ultimately a mechanism for the sector to demonstrate the value and impact that properly designed services can have. There is limited empirical understanding of the role of culturally-specific healthcare providers in terms of the service use patterns of these communities and overcoming the barriers that face Indigenous Australians attempting to access health services. Examining these issues through an economic lens is likely to provide a level of guidance to policy-makers that is currently absent from Indigenous health policy in Australia. This thesis explores these issues through a mixed-methods approach investigating the application and merits of a variety of health economic methods in these populations. Chapter 1 introduces the major issues in the field and provides an overview of the published literature carried out to date. Chapter 2 presents a more detailed investigation of the economic evaluation literature with a systematic review of published economic evaluations investigating health interventions in Indigenous populations around the world. The review finds relatively limited economic evaluation of health care interventions for Indigenous populations in Australia or globally, however, what has been done has demonstrated the potential for cost-effective interventions in these populations. Almost no consideration of alternative conceptions of health or Indigenous-specific values were found through the review. Chapter 3 examines this issue further, investigating the use of health-related quality of life (HRQoL) instruments in these populations, one of the most direct method to incorporate Indigenous conceptions of health into evaluations of health programs, through a systematic review of the use of these instruments in Indigenous populations around the world. The review found that while HRQoL instruments have been used to elicit the quality of life of Indigenous populations their use was relatively limited, as was evidence of the validation of these instruments in these population groups. The evidence that does exist suggests that some Indigenous populations potentially conceptualise these issues fundamentally differently to populations in which these tools have been designed and validated. Chapter 4 discusses the findings of the reviews presented in Chapters 2 and 3 in light of the Australian policy context. The chapter argues that the policy environment has emphasised rights-based rather than economic arguments in resource allocation decisions that has left room for efficiency and equity improvements in the way that resource allocation decisions are made in the field of Indigenous health. Given this, the chapter calls for further work to investigate the service utilisation of Indigenous populations and the role of culturally-specific healthcare providers and incorporate Indigenous values to value programs to improve Indigenous health including through contingent valuation and discrete choice experiment methodologies. Chapter 5 takes up the first of these issues with an analysis of the healthcare expenditure of a cohort of Indigenous and non-Indigenous Australians at high-risk of cardiovascular disease to investigate the relative service utilisation of the two groups. The analysis finds that when individuals are engaged with care providers, culturally-specific providers were providing equivalent care to mainstream providers in non-remote areas and factors other than patient Aboriginality seem to be more important in determining the healthcare expenditure of these high-risk patients. The chapter also highlights problems with current data collections in the field that acts to obscure analysis of service utilisation patterns of Indigenous Australians, particularly in remote areas, and comparisons between the relative service use of Indigenous and non-Indigenous Australians. Chapter 6 further investigates the role of culturally-specific service providers through a DCE attempting to value the cultural component of a fall-prevention service. The chapter presents the findings of a DCE carried out in a cohort of older Aboriginal people receiving a culturally-specific fall-prevention intervention. The chapter demonstrates that DCEs provide a potential means to incorporate the preferences of Indigenous communities into the design and evaluation of health services. A value for the cultural component of the service was derived through the DCE and the relative importance of different barriers to care to the decision-making of the participants were investigated. Chapter 7 presents the findings of a contingent valuation study investigating the value that the Australian community places on holding a driver licence as an example of a social determinant that has been shown to be associated with positive health outcomes in Indigenous populations. The analysis finds contingent valuation techniques can provide a means to value social determinants of health that lie outside traditional health economic evaluations and to value broader policy interventions to improve living standards. Chapter 8 puts forward the main findings of this thesis arguing that the health economics field has an important role to play in improving the health of Australia’s Indigenous populations. Appropriate targeting of available resources is essential to close the gap in health outcomes between Indigenous and non-Indigenous Australians. Economic research is vital to build an evidence-base for policy makers looking to invest in cost-effective policy options and this needs to be based on factors that Indigenous communities consider important to their health and healthcare. Potential for economic evaluation of programs needs to be a key consideration in resource allocation decisions in the field. These need to be robust enough to incorporate the factors that are important to Indigenous Australians. The role of culturally-specific providers needs to be better understood as do the different components that make up such a service. Finally, incorporating social determinants of health into the health policy environment remains crucial in the field of Indigenous health. Given the political, moral and economic importance of overcoming the disparities faced by Australia’s Aboriginal and Torres Strait Islander communities, the relative lack of health economic research in the sector is a failing of the field in Australia. Building an economic evidence base will assist those working in the sector to demonstrate the value of appropriately designed, culturally acceptable healthcare services and decision-makers in the field to move beyond rights-based arguments for funding decisions. Collectively this will enable a system of rational priority-setting in the sector whereby the health impacts derived from scarce resources are maximised

Control of infectious lameness in sheep

Lameness in sheep remains a significant welfare and economic issue for many UK sheep farms. The principle causes of lameness are the infectious foot diseases footrot and contagious ovine digital dermatitis. This article will review the recent research on the microbial aetiology, epidemiology, prevention and treatment of both diseases and the application of this knowledge into farm specific control plans utilising the Five Point Plan framework. </jats:p

Sheep and farm level factors associated with contagious ovine digital dermatitis: A longitudinal repeated cross-sectional study of sheep on six farms

Contagious ovine digital dermatitis (CODD) is a cause of severe lameness in sheep in the UK currently affecting approximately 50% of farms. Six farms were studied in North Wales to investigate (1) the prevalence dynamics of CODD, (2) the association between sheep with CODD and potential risk factors and (3) the impact of CODD on lameness in sheep. The farms were visited at approximately two-month intervals between June 2012 and October 2013 and 6515 sheep were examined. The mean sheep level prevalence of CODD varied between farms (2.5–11.9%). Within farms, prevalence may increase in the late summer/early autumn and after housing. Environmental risk factors included larger flocks, lowland pasture, lush pasture and poached pasture. Co-infection of a foot with footrot was strongly associated with CODD in that foot (OR: 7.7 95% CI: 3.9–15.5

Watery mouth disease in neonatal lambs: a systematic literature review

Watery mouth disease is considered to be a significant cause of neonatal mortality in lambs. The clinical signs are strongly associated with an endotoxaemia produced as a result of the lysis of Gram-negative bacteria. It has been associated with mass antibiosis to neonatal lambs at birth, a practice which is now untenable. It can be prevented in many cases through the timely administration of good quality colostrum and a hygienic birth environment. However, despite this, much remains unknown about the specific aetiopathogenesis. Alternative strategies for prevention, treatment and control are required, particularly when colostrum quality is poor, or delivery is absent, and where unhygienic conditions predominate. </jats:p

Contagious Ovine Digital Dermatitis: A Novel Bacterial Aetiology and Lesion Pathogenesis.

Contagious ovine digital dermatitis (CODD) is a severe and common infectious foot disease of sheep and a significant animal welfare issue for the sheep industry in the UK and some European countries. The aetiology and pathogenesis of the disease are incompletely understood. In this longitudinal, experimental study, CODD was induced in 18 sheep, and for the first time, the clinical lesion development and associated microbiological changes in CODD affected feet are described over time, resulting in a completely new understanding of the aetiopathogenesis of CODD. The majority of CODD lesions (83.9%) arose from pre-existing interdigital dermatitis (ID) and/or footrot (FR) lesions. All stages of foot disease were associated with high levels of poly-bacterial colonisation with five pathogens which were detected by qPCR; Treponema medium, Treponema phagedenis, Treponema pedis, Dichelobacter nodosus and Fusobacterium necrophorum. Temporal colonisation patterns showed a trend for early colonisation by Treponema phagedenis, followed by Fusobacterium necrophorum and Dichelobacter nodosus, Treponema medium and then Treponema pedis. Dichelobacter nodosus was present at significantly higher predicted mean log10 genome copy numbers in FR lesions compared to both ID and CODD whilst Treponema species were significantly higher in CODD & FR lesions compared to ID lesions (P < 0.001). Treatment of CODD affected sheep with 2 doses of 10mg/kg long acting amoxicillin resulted in a 91.7% clinical cure rate by 3 weeks post treatment, however a bacteriological cure was not established for all CODD affected feet. The study found that in an infected flock, healthy feet, healed CODD feet, and treated CODD feet can be colonised by some or all of the 5 pathogens associated with CODD and therefore could be a source of continued infection in flocks. The study is an experimental study and the findings require validation in field CODD cases. However, it does provide a new understanding of the aetiopathogenesis of CODD and further supportive evidence for the importance of current advice on the control of CODD; namely ensuring optimum flock control of footrot and prompt isolation and effective treatment of clinical cases

Ernst Freund as Precursor of the Rational Study of Corporate Law

Gindis, David, Ernst Freund as Precursor of the Rational Study of Corporate Law (October 27, 2017). Journal of Institutional Economics, Forthcoming. Available at SSRN: https://ssrn.com/abstract=2905547, doi: https://dx.doi.org/10.2139/ssrn.2905547The rise of large business corporations in the late 19th century compelled many American observers to admit that the nature of the corporation had yet to be understood. Published in this context, Ernst Freund's little-known The Legal Nature of Corporations (1897) was an original attempt to come to terms with a new legal and economic reality. But it can also be described, to paraphrase Oliver Wendell Holmes, as the earliest example of the rational study of corporate law. The paper shows that Freund had the intuitions of an institutional economist, and engaged in what today would be called comparative institutional analysis. Remarkably, his argument that the corporate form secures property against insider defection and against outsiders anticipated recent work on entity shielding and capital lock-in, and can be read as an early contribution to what today would be called the theory of the firm.Peer reviewe

Currency depreciation and the monetary adjustment process: Reconsidering Lord King's contributions

© Oxford University Press 2018, All rights reserved. This paper investigates Lord King's contributions in light of the renewed debate on international monetary policy coordination. We argue that King's work contains refined bullionist insights concerning currency depreciation, exchange rate determination, and balance of payments adjustment. We show how King's analysis of the monetary process under different currency regimes can help elucidate the effects of unconventional monetary policy on a global scale, concerning monetary spillovers, currency wars, business cycles, and the distribution of wealth

Has Behavioral Science Tumbled Through the Biological Looking Glass? Will Brief, Evidence-Based Training Return It From the Rabbit Hole?

Time constraints and professional demands leave practicing professionals unlikely to enroll in extended training such as a semester-long graduate course. Thus, the three-hour continuing education format has become a standard for those in practice. One may ask what sorts of training strategies optimize that format. To explore that, a three hour training program for seventy-six practicing mental health professionals, most of whom self-identified as psychologists, was devised. It made use of primarily antecedent techniques that have been shown to bring about changed perceptions on a number of topics. Content focused on two areas of importance to behavior analysts, the culture’s increasing acceptance of the biological causation model of disorders such as attentiondeficit hyperactivity disorder (ADHD), unipolar depression, anxiety disorders, and schizophrenia, and the field’s increasing reliance on medications, often to the exclusion of behavioral methods. Pre-post assessment showed that participants had changed their thinking regarding the two content areas. The authors caution that participants’ changed opinions may serve as setting events to changes in practice, but those changes are verbal. One must not assume changes in practice techniques will automatically occur

Cellular Model of Warburg Effect Identifies Tumor Promoting Function of UCP2 in Breast Cancer and Its Suppression by Genipin

The Warburg Effect is characterized by an irreversible injury to mitochondrial oxidative phosphorylation (OXPHOS) and an increased rate of aerobic glycolysis. In this study, we utilized a breast epithelial cell line lacking mitochondrial DNA (rho0) that exhibits the Warburg Effect associated with breast cancer. We developed a MitoExpress array for rapid analysis of all known nuclear genes encoding the mitochondrial proteome. The gene-expression pattern was compared among a normal breast epithelial cell line, its rho0 derivative, breast cancer cell lines and primary breast tumors. Among several genes, our study revealed that over-expression of mitochondrial uncoupling protein UCP2 in rho0 breast epithelial cells reflects gene expression changes in breast cancer cell lines and in primary breast tumors. Furthermore, over-expression of UCP2 was also found in leukemia, ovarian, bladder, esophagus, testicular, colorectal, kidney, pancreatic, lung and prostate tumors. Ectopic expression of UCP2 in MCF7 breast cancer cells led to a decreased mitochondrial membrane potential and increased tumorigenic properties as measured by cell migration, in vitro invasion and anchorage independent growth. Consistent with in vitro studies, we demonstrate that UCP2 over-expression leads to development of tumors in vivo in an orthotopic model of breast cancer. Genipin, a plant derived small molecule, suppressed the UCP2 led tumorigenic properties, which were mediated by decreased reactive oxygen species and down-regulation of UCP2. However, UCP1, 3, 4 and 5 gene expression was unaffected. UCP2 transcription was controlled by SMAD4. Together, these studies suggest a tumor-promoting function of UCP2 in breast cancer. In summary, our studies demonstrate that i) the Warburg Effect is mediated by UCP2; ii) UCP2 is over-expressed in breast and many other cancers; iii) UCP2 promotes tumorigenic properties in vitro and in vivo and iv) genipin suppresses the tumor promoting function of UCP2