Variation in the costs of healthcare for chronic disease in Australia: The case of asthma, CHERE Working Paper 2008/7

Objectives Individuals with chronic conditions represent a high healthcare cost group and understanding the cost variation among individuals is important for developing appropriate policy. This study aimed to investigate the sources of variation in the cost of healthcare for a cohort of people with asthma. It examines the costs to the health system and patient out-of-pocket costs. Methods A longitudinal observational study of asthma-related healthcare costs in a cohort of people with asthma (n=252). Participants were followed for three years using six-monthly postal surveys and individual administrative data. The factors associated with health system and patient out-of-pocket costs were investigated using generalised linear mixed models. Results There was substantial variability around the average costs of healthcare for asthma which were associated with asthma-related health measures and socio-demographic variables. The health system costs were less for those living in regional areas relative to Sydney residents and both the health system and patient out-of-pocket costs were highest in the oldest age group and lowest for children. The health system and patient out-of-pocket costs were highest for the high income group while the middle income group had the lowest total cost. Conclusions Our findings suggest that variations should be explored in developing strategies for chronic disease management and that Australia has achieved reasonable equity in access. However, out-of-pocket costs may be a deterrent for the middle income group, which should be a general concern for policies targeting the most disadvantaged group to the exclusion of concern with universal access.asthma, out-of-pocket costs, Australia

The provision of informal care in terminal illness: An analysis of carers? needs using a discrete choice experiment

There is an increasing expectation that families will provide care at home for those with chronic, acute and terminal illness. There is a range of services available to support the home care of these patients. Carers of those in the terminal phase of illness face different demands and challenges than those caring for the chronically ill, disabled or aging; the patient?s health is deteriorating, often rapidly, and death is imminent. Yet the needs and requirements of this group of carers has been far less studied than those caring for people with chronic and continuing conditions. We argue that considering the reciprocal nature of relationships is important in understanding the provision of informal care. Carers? feelings for which tasks and responsibilities are most difficult are not the same as their preferences for additional support services. Carers preferences are influenced by their relationship with the patient. This study investigates carers? preferences for services to support their caregiving role. Carer preferences were investigated using a discrete choice experiment, in which 168 carers were asked first to choose between two packages of care and then between the chosen package and their current support. Data were analysed using mixed logit. The DCE results showed that the support most wanted was palliative care nursing, general nursing, and telephone advice available 24 hours. Carers providing high levels of care wanted respite care provided at home and help with the patient?s personal care. Where the care-giving need was relatively low, carers wanted help with household tasks, transport and a case co-ordinator. Overall, carers appeared to be satisfied with the support they received from palliative care services, but this varied with the personal circumstances of the carer. This study provides useful insights for those who plan and deliver palliative care in the community. It supports the view that effective support for carers must recognise the differing needs of individual carers. While our results do not provide any insight into how the pre-existing relationship between carer and recipient may affect preferences for care, it points to the need to explore further differences in preferences across respondents both in discrete choice work in general, and in designing services to support rather than replace informal carers.Informal care; carer's perspective; discrete choce experiment

Using qualitative methods to validate a stated preference survey for evaluating health services, CHERE Discussion Paper No 47

This study used a qualitative approach to assess parents? opinions of a self-completed stated preference discrete choice modelling (SPDCM) questionnaire for assessing the uptake of a new childhood vaccination against chickenpox. The aim was to assess the way parents understood and used the technical information provided, the factors they deemed important to decisions about childhood immunisation and the extent to which these were consistent with the models produced by analysis of the questionnaire data. Following completion of the SPDCM questionnaire, 34 respondents participated in a semi-structured interview by telephone. Interview transcripts were analysed using content analysis. Comparisons were then made with the SPDCM questionnaire results. The technical information used to describe the program attributes appeared to be used appropriately by respondents, although their explanations indicated that their understanding did not always come from the questionnaire information. Only one respondent appeared to misunderstand the stated preference task, and a small number thought that the complexity and length should be reduced. The group results for the questionnaire data were supported by the qualitative study, with the notable features of the model being reflected in the views commonly expressed about the immunisation decision. Generally, the study provides support for the potential usefulness of the SPDCM methodology for predicting the uptake of a new vaccination.Discrete choice modelling, questionnaires, methodology

Diaries or questionnaires for collecting self-reported healthcare utilisation and patient cost data? CHERE Project Report No 20

The literature comparing diaries and questionnaires was reviewed in order to identify the most appropriate method of collecting patient self-reported data, on health service utilisation and out-ofpocket costs, for a longitudinal study. Nine published studies met the review inclusion criteria; four compared the diary method with a self-completed questionnaire and five with an interviewer administered questionnaire. None of the eligible studies measured patient costs, and only two measured some aspects of health service utilisation. Most of the studies reported higher response rates for questionnaires than for diaries, and there was some evidence of selection bias. There was a tendency to report more symptoms, symptom intensity or health care utilisation by questionnaires compared to diaries, and compared to physician reports (included in only two studies). The review provides some information about the two approaches for collecting self-reported data, but does not provide sufficient evidence to favour either approach.diaries, health care utilisation

Sources of variation in the costs of health care for asthma patients in Australia

Objectives: Individuals with chronic conditions, such as asthma, on average incur high health care costs, though good control can reduce costs and improve health outcomes. However, there may be substantial variation between patients in their use of services and therefore costs. Our objective was to investigate the sources of such variation in health system and out-of-pocket costs for people with asthma. Methods: A longitudinal observational study of 252 people with asthma in New SouthWales, Australia, followed for three years, using six-monthly postal surveys and individual administrative data. Factors associated with costs were investigated using generalized linear mixed models. Results: There was substantial variability in costs between individuals but relatively little within-person change over time for the majority. Costs to the health system and out-of-pocket costs were higher with increasing asthma-related health problems and increasing age. Health system costs were less for patients living outside the state capital (Sydney) and for those in the middle income group relative to high and low income groups. Conclusions: Those with poorly-controlled asthma and the elderly require more carefully targeted strategies to improve their health and ensure appropriate use of resources. Access to appropriate services for those living outside of major cities should be improved. Co-payments for the middle-income groups and those living outside major cities should be reduced to improve equity in the use of services. © The Royal Society of Medicine Press Ltd 2009

Informal care and home-based palliative care: The health-related quality of life of carers

Health is an important factor in the capacity of family and friends (informal carers) to continue providing care for palliative care patients at home. This study investigates associations between the health-related quality of life (HRQOL) of current informal carers and characteristics of the carers and their caregiving situation, in a sample of Australian carers of palliative care patients. The cross-sectional study used the Short Form-36 Health Survey to measure HRQOL. It found carers to have better physical health and worse mental health than the general population. Of 178 carers, 35% reported their health to be worse than it was one year ago. Multiple regression analyses found that the HRQOL of carers whose health had deteriorated in the previous year was associated with the patient's care needs but not the carer's time input, unlike the carers reporting stable health. Clinicians caring for palliative care patients should be alert to the potential health impairments of informal carers and ensure that they are adequately supported in their caregiving role and have access to appropriate treatment and preventive health care. © 2010 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc

Using discrete choice experiments to investigate subject preferences for preventive asthma medication

Background and objective: Long-term adherence to inhaled corticosteroids is poor despite the crucial role of preventer medications in achieving good asthma outcomes. This study was undertaken to explore patient preferences in relation to their current inhaled corticosteroid medication, a hypothetical preventer or no medication. Methods: A discrete choice experiment was conducted in 57 adults with mild-moderate asthma and airway hyper-responsiveness, who were using inhaled corticosteroid ≤500 μg/day (beclomethasone equivalent). In the discrete choice experiment, subjects evaluated 16 hypothetical scenarios made up of 10 attributes that described the process and outcomes of taking asthma medication, with two to four levels for each attribute. For each scenario, subjects chose between the hypothetical medication, the medication they were currently taking and no asthma medication. A random parameter multinomial logit model was estimated to quantify subject preferences for the aspects of taking asthma medication and the influence of attributes on medication decisions. Results: Subjects consistently made choices in favour of being able to do strenuous and sporting activities with or without reliever, experiencing no side-effects and never having to monitor their peak flow. Frequency of collecting prescriptions, frequency of taking the medication, its route of administration and the strength of the doctor recommendation about the medication were not significant determinants of choice. Conclusions: The results of this study suggest that patients prefer a preventer that confers capacity to maximize physical activity, has no side-effects and does not require daily peak flow monitoring. © 2007 The Authors

What is news? News values revisited (again)

The deceptively simple question “What is news?” remains pertinent even as we ponder the future of journalism in the digital age. This article examines news values within mainstream journalism and considers the extent to which news values may be changing since earlier landmark studies were undertaken. Its starting point is Harcup and O’Neill’s widely-cited 2001 updating of Galtung and Ruge’s influential 1965 taxonomy of news values. Just as that study put Galtung and Ruge’s criteria to the test with an empirical content analysis of published news, this new study explores the extent to which Harcup and O’Neill’s revised list of news values remain relevant given the challenges (and opportunities) faced by journalism today, including the emergence of social media. A review of recent literature contextualises the findings of a fresh content analysis of news values within a range of UK media 15 years on from the last study. The article concludes by suggesting a revised and updated set of contemporary news values, whilst acknowledging that no taxonomy can ever explain everything

Westmead hospital team midwifery project evaluation, CHERE Project Report No 4

midwifery, evaluation, Australia