Mapping the Strengths and Difficulties Questionnaire onto the Child Health Utility 9D in a large study of children

Purpose Non-preference-based measures cannot be used to directly obtain utilities but can be converted to preference-based measures through mapping. The only mapping algorithm for estimating Child Health Utility-9D (CHU9D) utilities from Strengths and Difficulties Questionnaire (SDQ) responses has limitations. This study aimed to develop a more accurate algorithm. Methods We used a large sample of children (n = 6898), with negligible missing data, from the Longitudinal Study of Australian Children. Exploratory factor analysis (EFA) and Spearman’s rank correlation coefficients were used to assess conceptual overlap between SDQ and CHU9D. Direct mapping (involving seven regression methods) and response mapping (involving one regression method) approaches were considered. The final model was selected by ranking the performance of each method by averaging the following across tenfold cross-validation iterations: mean absolute error (MAE), mean squared error (MSE), and MAE and MSE for two subsamples where predicted utility values were  0.90 (healthy). External validation was conducted using data from the Child and Adolescent Mental Health Services study. Results SDQ and CHU9D were moderately correlated (ρ = − 0.52, p < 0.001). EFA demonstrated that all CHU9D domains were associated with four SDQ subscales. The best-performing model was the Generalized Linear Model with SDQ items and gender as predictors (full sample MAE: 0.1149; MSE: 0.0227). The new algorithm performed well in the external validation. Conclusions The proposed mapping algorithm can produce robust estimates of CHU9D utilities from SDQ data for economic evaluations. Further research is warranted to assess the applicability of the algorithm among children with severe health problems

Financial cost of lymphedema borne by women with breast cancer

Psycho-Oncology Published by John Wiley & Sons Ltd.Objective: Our study examines the financial cost of lymphedema following a diagnosis of breast cancer and addresses a significant knowledge gap regarding the additional impact of lymphedema on breast cancer survivors. Methods: An online national survey was conducted with 361 women who had either breast cancer without lymphedema (BC) (group 1, n = 209) or breast cancer with lymphedema (BC+LE) (group 2, n = 152). Participant recruitment was supported by the Breast Cancer Network Australia and the Australasian Lymphology Association. Results: Both breast cancer and lymphedema result in significant out-of-pocket financial costs borne by women. Of patients with BC+LE, 80% indicated that their breast cancer diagnosis had affected them financially compared with 67% in the BC group (P \u3c .020). For patients with lymphedema, over half (56%) indicated that this specific additional diagnosis to their breast cancer affected them financially and that costs increased with lymphedema severity. The cost of compression garments formed a large proportion of these costs (40.1%). The average number of attendances to a therapist each year was 5.8 (range, 0-45). Twenty-five patients (16.4%) had an episode of cellulitis in the past year. The incidence of cellulitis was 7.7% in 91 patients with subclinical or mild lymphedema compared with 29.5% of 61 patients with more extensive lymphedema (P \u3c .001). The average out-of-pocket financial cost of lymphedema care borne by women was A$977 per annum, ranging from A$207 for subclinical lymphedema to over A$1400 for moderate or severe lymphedema. Conclusions: This study identifies an additional detrimental effect of lymphedema on women in terms of financial costs

Resource use, costs and quality of end-of-life care: Observations in a cohort of elderly Australian cancer decedents

© Commonwealth of Australia; licensee BioMed Central Ltd. Background: The last year of life is one of the most resource-intensive periods for people with cancer. Very little population-based research has been conducted on end-of-life cancer care in the Australian health care setting. The objective of this program is to undertake a series of observational studies examining resource use, costs and quality of end-of-life care in a cohort of elderly cancer decedents using linked, routinely collected data. Methods/Design: This study forms part of an ongoing cancer health services research program. The cohorts for the end-of-life research program comprise Australian Government Department of Veterans' Affairs decedents with full health care entitlements, residing in NSW for the last 18 months of life and dying between 2005 and 2009. We used cancer and death registry data to identify our decedent cohorts and their causes of death. The study population includes 9,862 decedents with a cancer history and 15,483 decedents without a cancer history. The median age at death is 86 and 87 years in the cancer and non-cancer cohorts, respectively. We will examine resource use and associated costs in the last 6 months of life using linked claims data to report on health service use, hospitalizations, emergency department visits and medicines use. We will use best practice methods to examine the nature and extent of resource use, costs and quality of care based on previously published indicators. We will also examine factors associated with these outcomes. Discussion: This will be the first Australian research program and among the first internationally to combine routinely collected data from primary care and hospital-based care to examine comprehensively end-of-life care in the elderly. The research program has high translational value, as there is limited evidence about the nature and quality of care in the Australian end-of-life setting

Authors' reply to Palozzo and Messori : "Disinvestment and value-based purchasing strategies for pharmaceuticals : an international review"

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Considering consumer choice in the economic evaluation of mandatory health programmes: A review

Objective Governments are increasing their focus on mandatory public health programmes following positive economic evaluations of their impact. This review aims to examine whether loss of consumer choice should be included in economic evaluations of mandatory health programmes (MHP).Method A systematic literature review was conducted to identify economic evaluations of MHP, whether they discuss the impact on consumer choice and any methodological limitations.Results Overall 39 economic evaluations were identified, of which 10 discussed the loss of consumer choice and 6 attempted to place a value on the loss of consumer choice. Methodological limitations included: measuring the marginal cost of compliance, unavailability of price elasticity estimates, the impact of income effects, double counting health impacts, biased willingness-to-pay responses, and "protest" responses. Overall it was found that the inclusion of the loss of consumer choice rarely impacted on the final outcome of the study.Conclusion The impact of MHP on the loss of consumer choice has largely been ignored in economic evaluations. Its importance remains uncertain due to its infrequent inclusion and significant methodological limitations. Further research regarding which methodology is best for valuing the loss of consumer choice and whether it is important to the final implementation decision is warranted.Mandatory programs Economics Public opinion Consumer choice Cost-benefit analysis

Economic evaluations of trastuzumab in HER₂-positive metastatic breast cancer : a systematic review and critique

BACKGROUND: Published economic evaluations of trastuzumab for the treatment of HER₂-positive metastatic breast cancer have arrived at different conclusions regarding the cost-effectiveness of trastuzumab, despite comparative efficacy being demonstrated by a small set of randomised controlled trials (RCTs). OBJECTIVES: This article aims to provide insight into the quality of the evaluations and explore the possible drivers of the conflicting conclusions. METHODS: A systematic literature review was conducted to identify all published economic evaluations that compared the incremental costs and outcomes of trastuzumab versus a comparator. RESULTS: Fifteen economic evaluations were identified. In the evaluations that estimated efficacy using an RCT, the key drivers of the conclusions regarding cost-effectiveness were: the approach used to estimate overall survival in the control group given crossover to trastuzumab following progression in the trials; the inclusion of treatment beyond progression; inclusion of wastage due to unused vial portions, adverse events, and the cost of HER₂ testing. Four evaluations used non-randomised approaches to estimate efficacy, thus introducing the potential for confounding. As a result these evaluations reported relatively optimistic estimates of comparative effectiveness. Finally the evaluations used different thresholds to determine whether treatment with trastuzumab was cost-effective. CONCLUSION: There were numerous drivers of the different conclusions regarding the cost-effectiveness of trastuzumab, many of which are due to judgements made by the authors when translating data from RCTs. Many of the potential drivers were not identified by the published systematic reviews of economic evaluations and perhaps more remain unidentified because of inconsistent and limited reporting.20 page(s

Disinvestment and value-based purchasing strategies for pharmaceuticals : an international review

Pharmaceutical expenditure has increased rapidly across many OECD countries over the past three decades. This growth is an increasing concern for Governments and other third party payers seeking to provide equitable and comprehensive healthcare within sustainable budgets. In order to create headroom for increasing utilisation, and to fund new high cost therapies there is an active push to ‘disinvest’ from low-value drugs. The aim of this article is to review how reimbursement policy decision makers have sought to partially or completely disinvest from drugs in a range of OECD countries (UK, France, Canada, Australia and New Zealand) where they are publicly funded or subsidised. We employed a systematic literature search strategy and the incorporation of grey literature known to the authorship team. We canvass key policy instruments from each country to outline: key approaches to the identification of candidate drugs for disinvestment assessment (passive approaches versus more active approaches); Methods of disinvestment and value-based purchasing: de-listing, restricting treatment, price or reimbursement rate reductions, encouraging generic prescribing; Lessons learnt from the various approaches; The potential role of coverage with evidence development, and; The need for careful stakeholder management. Dedicated sections are provided with detailed coverage of policy approaches (with drug examples) from each country. Historically countries have relied on ‘passive disinvestment’, however due to (i) the availability of new cost-effectiveness evidence or (ii) ‘leakage’ in drug utilisation or (iii) market failure in terms of price competition, there is an increasing focus towards ‘active disinvestment’. Isolating low-value drugs that would create headroom for innovative new products to enter the market is also motivating disinvestment efforts by multiple parties, including industry. Historically disinvestment has mainly taken the form of price reductions, especially when market failures are perceived to exist, and restricting treatment to sub-populations, particularly when a drug is no longer considered value for money. There is considerable experimentation internationally in mechanisms for disinvestment and the opportunity for countries to learn from each other. Ongoing evaluation of disinvestment strategies is essential, and ought to be reported in the peer-reviewed literature

Hide and Seek with Hereditary Cancer: Evaluating a Theory Grounded Approach to Implementing Systems Change to Appropriately Detect and Refer Lynch Syndrome Patients

Lynch syndrome (LS) is an inherited cancer syndrome which significantly increases a carriers lifetime risk of several cancers, most notably colorectal cancer (CRC). There are an estimated 19 040 carriers in NSW, with approximately 1:250 people carrying the gene fault associated with LS. Recent Australian data has shown that up to 54% of CRC patients with suspicious LS phenotypes were not referred for genetic testing. Evidence indicates that hospitals face a plethora of infrastructure, psychosocial and environmental barriers to successfully implementing appropriate referral strategies to detect LS patients. This study aims to discover whether a theory grounded approach to implementing guidelines for appropriately identifying LS patients is more effective than a non-theory grounded approach. This will be an Interrupted time series design (ITS) in 10 hospitals across three Australian states (NSW, VIC, WA). Once matched for size and pathology laboratories, hospitals will be randomly allocated to either the intervention (using a theory grounded approach to implementation) or an active control group (non-theory grounded approach to implementation). Translational genetics coordinators will be trained to deliver the implementation approaches, and provided with support from the research team during the following phases: forming an implementation team, identifying baseline audit data and target behaviours for change, identifying barriers to referral, co-designing interventions, implementation, and evaluation of change. Outcome measures will be (a) the change in the proportion of CRC patients appropriately tumour tested in both study arms. This will be evaluated through the collection of date-stamped pathology data; (b) the change in proportion of appropriate LS referrals made to Familial Cancer Clinic. This is the first Australian study that will determine the effectiveness of a theoretical approach in translating genomic evidence based policy in improving both detection and referral outcomes in comparison to a non-theory based implementation approach