How can information and communication technology improve healthcare inequalities and healthcare inequity? The concept of context driven care

Advances in medicine have improved health and healthcare for many around the world. The challenge is achieving the best outcomes of health via healthcare delivery to every individual. Healthcare inequalities exist within a country and between countries. Health information technology (HIT) has provided a mean to deliver equal access to healthcare services re-gardless of social context and physical location. In order to achieve better health outcomes for every individual, socio-cultural factors, such as literacy and social context need to consider. This paper argues that HIT while im-proves healthcare inequalities by providing access, might worsen healthcare inequity. In order to improve healthcare inequity using HIT, this paper ar-gues that we need to consider patients and context, and hence the concept of context driven care. To improve healthcare inequity, we need to conceptual-ly consider the patient’s view and methodologically consider design meth-ods that achieve participatory outcomes

Quality of life utility values for hereditary haemochromatosis in Australia

Background: Hereditary hemochromatosis (HH) is a common autosomal recessive disorder amongst persons of northern European heritage. If untreated, iron accumulates in parenchymal tissues causing morbidity and mortality. As diagnosis often follows irreversible organ damage, screening programs have been suggested to increase early diagnosis. A lack of economic evidence has been cited as a barrier to establishing such a program. Previous analyses used poorly estimated utility values. This study sought to measure utilities directly from people with HH in Australia. Methods: Volunteers with HH were recruited to complete a web-based survey. Utility was assessed using the Assessment of Quality of Life 4D (AQOL-4D) instrument. Severity of HH was graded into four categories. Multivariable regression analysis was performed to identify parameters associated with HSUV. Results: Between November 2013 and November 2014, 221 people completed the survey. Increasing severity of HH was negatively associated with utility. Mean (standard deviation) utilities were 0.76 (0.21), 0.81 (0.18), 0.60 (0.27), and 0.50 (0.27) for categories 1-4 HH respectively. Lower mean utility was found for symptomatic participants (categories 3 and 4) compared with asymptomatic participants (0.583 v. 0.796). Self-reported HH-related symptoms were negatively associated with HSUV (r = -0.685). Conclusions: Symptomatic stages of HH and presence of multiple self-reported symptoms were associated with decreasing utility. Previous economic analyses have used higher utilities which likely resulted in underestimates of the cost effectiveness of HH interventions. The utilities reported in this paper are the most robust available, and will contribute to improving the validity of future economic models for HH

AI and Clinical Decision Making: The Limitations and Risks of Computational Reductionism in Bowel Cancer Screening

Advances in artificial intelligence in healthcare are frequently promoted as ‘solutions’ to improve the accuracy, safety, and quality of clinical decisions, treatments, and care. Despite some diagnostic success, however, AI systems rely on forms of reductive reasoning and computational determinism that embed problematic assumptions about clinical decision-making and clinical practice. Clinician autonomy, experience, and judgement are reduced to inputs and outputs framed as binary or multi-class classification problems benchmarked against a clinician’s capacity to identify or predict disease states. This paper examines this reductive reasoning in AI systems for colorectal cancer (CRC) to highlight their limitations and risks: (1) in AI systems themselves due to inherent biases in (a) retrospective training datasets and (b) embedded assumptions in underlying AI architectures and algorithms; (2) in the problematic and limited evaluations being conducted on AI systems prior to system integration in clinical practice; and (3) in marginalising socio-technical factors in the context-dependent interactions between clinicians, their patients, and the broader health system. The paper argues that to optimise benefits from AI systems and to avoid negative unintended consequences for clinical decision-making and patient care, there is a need for more nuanced and balanced approaches to AI system deployment and evaluation in CRC

Costs associated with hereditary haemochromatosis in Australia: a cost-of-illness study

Objective: The aim of the present study was to assess health sector, other sector and time-related (productivity) costs associated with hereditary haemochromatosis from societal, government and patient perspectives for the Australian setting. Methods: A national web-based survey of people with haemochromatosis was conducted between November 2013 and February 2015. Participants completed a health survey and resource use diaries. Costs were calculated using a bottom-up approach and calculated in 2015 Australian dollars. Results: Cost data were available for 157 participants. From a societal perspective, the estimated annual cost of haemochromatosis was A$274 million. The mean (95$10 030 (7705–12670) vs A$3701 (2423–5296) respectively). Health sector and productivity-related time loss were the main cost drivers. When extrapolating costs to the Australian population level, asymptomatic haemochromatosis accounted for higher costs than symptomatic haemochromatosis (A$183 million vs A$91 million), reflecting the low clinical penetrance estimate used. Total costs increased when higher clinical penetrance estimates were used. Conclusion: The present cost-of-illness study, the first to be published for haemochromatosis, found that although costs were substantial, they could be decreased by reducing clinical penetrance. Development of cost-effective strategies to increase early diagnosis is likely to result in better health outcomes for patients and lower total costs. What is known about the topic?: To date, no cost-of-illness study has been conducted for haemochromatosis. Previous economic work in this area has relied on cost estimates based on expert opinion. What does the paper add?: This paper provides the first cost estimates for haemochromatosis for the Australian population. These estimates, calculated using a bottom-up approach, were extrapolated to the population level based on the most robust epidemiological estimates available for the Australian population. What are the implications for practitioners?: Population screening programs have been widely suggested as an approach to reduce clinical penetrance; however, the lack of high-quality economic analyses has been cited as a barrier to implementation. The present study provides the most robust cost estimates to date, which may be used to populate economic models. In addition, the present study illustrates that reducing clinical penetrance of haemochromatosis is likely to result in substantial reductions in cost

A Systematic Review and Narrative Synthesis of Health Economic Studies Conducted for Hereditary Haemochromatosis

Background: Hereditary haemochromatosis (HH) is a common genetic condition amongst people of northern European heritage. HH is associated with increased iron absorption leading to parenchymal organ damage and multiple arthropathies. Early diagnosis and treatment prevents complications. Population screening may increase early diagnosis, but no programmes have been introduced internationally: a paucity of health economic data is often cited as a barrier.  Objective: To conduct a systematic review of all health economic studies in HH.  Methods: Studies were identified through electronic searching of economic/biomedical databases. Any study on HH with original economic component was included. Study quality was formally assessed. Health economic data were extracted and analysed through narrative synthesis.  Results: Thirty-eight studies met the inclusion criteria. The majority of papers reported on costs or cost effectiveness of screening programmes. Whilst most concluded screening was cost effective compared with no screening, methodological flaws limit the quality of these findings. Assumptions regarding clinical penetrance, effectiveness of screening, health-state utility values (HSUVs), exclusion of early symptomatology (such as fatigue, lethargy and multiple arthropathies) and quantification of costs associated with HH were identified as key limitations. Treatment studies concluded therapeutic venepuncture was the most cost-effective intervention.  Conclusions: There is a paucity of high-quality health economic studies relating to HH. The development of a comprehensive HH cost-effectiveness model utilising HSUVs is required to determine whether screening is worthwhile

Patient safety and sociotechnical considerations for electronic handover tools in an Australian ehealth landscape

The Australian Commission for Safety and Quality in Health Care (ACSQHC) coordinates national improvements in a range of complex health system problems including clinical handover, and has funded a range of handover improvement projects in Australia. One of these, the SafeTECH project in South Australia has developed guidelines for safe use of electronic handover tools. These guidelines were developed using evidence from three hospital case studies into the use of an electronic tool to support different types of shift-to-shift handover. This paper provides an overview of the project, and highlights challenges for patient safety in the design and use of electronic tools to support clinical handover in a busy clinical environment. The paper then considers these challenges within the broader context of the Australian ehealth landscape. Australia’s National eHealth Transition Authority (NEHTA) is actively developing ehealth standards and infrastructure requirements for the electronic collection and secure exchange of health information. The paper argues for flexible standardisation in the design and implementation of electronic handover tools to ensure that all key dimensions of the challenges faced in ensuring patient safety are addressed

Cost-Effectiveness of Different Population Screening Strategies for Hereditary Haemochromatosis in Australia

Introduction: Amongst populations of northern European ancestry, HFE-associated haemochromatosis is a common genetic disorder characterised by iron overload. In the absence of treatment, excess iron is stored in parenchymal tissues, causing morbidity and mortality. Population screening programmes may increase early diagnosis and reduce associated disease. No contemporary health economic evaluation has been published for Australia. The objective of this study was to identify cost-effective screening strategies for haemochromatosis in the Australian setting. Methods: A Markov model using probabilistic decision analysis was developed comparing four adult screening strategies: the status quo (cascade and incidental screening), genotyping with blood and buccal samples and transferrin saturation followed by genotyping (TfS). Target populations were males (30 years) and females (45 years) of northern European ancestry. Cost-effectiveness was estimated from the government perspective over a lifetime horizon. Results: All strategies for males were cost-effective compared to the status quo. The incremental costs (standard deviation) associated with genotyping (blood) were AUD7 (56), TfS AUD15 (45) and genotyping (buccal) AUD63 (56), producing ICERs of AUD1673, 4103 and 15,233/quality-adjusted life-year (QALY) gained, respectively. For females, only the TfS strategy was cost-effective, producing an ICER of AUD10,195/QALY gained. Approximately 3% of C282Y homozygotes were estimated to be identified with the status quo approach, compared with 40% with the proposed screening strategies. Conclusion: This model estimated that genotyping and TfS strategies are likely to be more cost-effective screening strategies than the status quo