The Cost of Waiting on an Orthopaedic Waiting List: a scoping review

Background: Approximately 30% Australians suffer from arthritis and other musculoskeletal disorders. From 2003-2033 there is a predicted 223% increase in expenditure on health management of musculoskeletal disorders. There is evidence of increasing prevalence of orthopaedic complaints, in longer waiting lists for specialist consultations in public hospital outpatient clinics. Little is known about the costs and ramifications of waiting for orthopaedic consultations. Aim: Establish what is known about the direct and indirect costs of being placed on a waiting list for an orthopaedic consultation. Method: Patient and Outcome search strategy of Medline, Embase, Pubmed, NHS Economic evaluation database (NHS-EED) from each database inception date. Handsearching of reference lists of included papers alsooccurred. A realist synthesis framework underpinned the review, using a ubiquitous patient journey to map available literature on the impact of waiting. Hierarchy of evidence was reported using NHMRC criteria andarticles critically appraised using either the PEDRo or CASP criteria (relevant to the design). A purpose-built data extraction instrument was developed. Results: We identified 786 studies, of which 139 were relevant, including a systematic review (Hoogeboom et al) with 15 included articles which were added to the list of eligible papers (and the review itself deleted), leaving 153 included articles; 17 were relevant to the review. Fourteen papers reported on quality of life and four reported on costs, two of these papers reported on both and all were of low to moderate quality. The research was not based on a comprehensive understanding of the stages of waiting, and there were inconclusive outcomes for quality of life and cost. Conclusion: There is scant evidence of the impact on quality of life and costs of waiting for orthopaedic outpatient appointments. Future research should aim for improved methodological quality and use patientfocused quality of life measures, and validated measures of cost. Abbreviations: NHMRC – National Health and Medical Research Council; PROMS – Patient Related Outcome Measures; QoL – Quality of Life; WOMAC – Western Ontario and McMaster Universities Osteoarthritis Index; YLD – Years Lived With Disabilit

Estimated Therapy Costs and Downstream Cost Consequences of iBASIS-Video Interaction to Promote Positive Parenting Intervention vs Usual Care Among Children Displaying Early Behavioral Signs of Autism in Australia

IMPORTANCE: The growing global prevalence of autism spectrum disorder (ASD) is associated with increasing costs for support services. Ascertaining the effects of a successful preemptive intervention for infants showing early behavioral signs of autism on human services budgets is highly policy relevant.OBJECTIVE: To estimate the net cost impact of the iBASIS-Video Interaction to Promote Positive Parenting (iBASIS-VIPP) intervention on the Australian government.DESIGN, SETTING, AND PARTICIPANTS: Infants (aged 12 months) showing early behavioral indicators of autism were recruited through community settings into the multicenter Australian iBASIS-VIPP randomized clinical trial (RCT), a 5- to 6-month preemptive parent-mediated intervention, between June 9, 2016, and March 30, 2018, and were followed up for 18 months to age 3 years. This economic evaluation, including cost analysis (intervention and cost consequences) and cost-effectiveness analyses of iBASIS-VIPP compared with usual care (treatment as usual [TAU]), modeled outcomes observed at age 3 through to 12 years (13th birthday) and was conducted from April 1, 2021, to January 30, 2023. Data analysis was conducted from July 1, 2021, to January 29, 2023.EXPOSURES: iBASIS-VIPP intervention.MAIN OUTCOMES AND MEASURES: To project the diagnostic trajectory and associated disability support costs drawing on the Australian National Disability Insurance Scheme (NDIS), the main outcome was the differential treatment cost of iBASIS-VIPP plus TAU vs TAU and disability-related government costs modeled to age 12 years, using a clinical diagnosis of ASD and developmental delay (with autism traits) at 3 years. Costs were calculated in Australian dollars and converted to US dollars. Economic performance was measured through the following: (1) differential net present value (NPV) cost (iBASIS-VIPP less TAU), (2) investment return (dollars saved for each dollar invested, taking a third-party payer perspective), (3) break-even age when treatment cost was offset by downstream cost savings, and (4) cost-effectiveness in terms of the differential treatment cost per differential ASD diagnosis at age 3 years. Alternate values of key parameters were modeled in 1-way and probabilistic sensitivity analysis, the latter identifying the likelihood of an NPV cost savings.RESULTS: Of the 103 infants enrolled in the iBASIS-VIPP RCT, 70 (68.0%) were boys. Follow-up data at age 3 years were available for 89 children who received TAU (44 [49.4%]) or iBASIS-VIPP (45 [50.6%]) and were included in this analysis. The estimated mean differential treatment cost was A $5131 (US$3607) per child  for iBASIS-VIPP less TAU. The best estimate of NPV cost savings was A $10 695 (US$7519) per child (discounted at 3% per annum). For each dollar invested in treatment, a savings of A $3.08 (US$3.08) was estimated; the break-even cost occurred at age 5.3 years (approximately 4 years after intervention delivery). The mean differential treatment cost per lower incident case of ASD was A $37 181 (US$26 138). We estimated that there was an 88.9% chance that iBASIS-VIPP would deliver a cost savings for the NDIS, the dominant third-party payer.CONCLUSIONS AND RELEVANCE: The results of this study suggest that iBASIS-VIPP represents a likely good-value societal investment for supporting neurodivergent children. The estimated net cost savings were considered conservative, as they covered only third-party payer costs incurred by the NDIS and outcomes were modeled to just age 12 years. These findings further suggest that preemptive interventions may be a feasible, effective, and efficient new clinical pathway for ASD, reducing disability and the costs of support services. Long-term follow-up of children receiving preemptive intervention is needed to confirm the modeled results.</p