A cost effectiveness study of integrated care in health services delivery: a diabetes program in Australia

BACKGROUND: Type 2 diabetes is rapidly growing as a proportion of the disease burden in Australia as elsewhere. This study addresses the cost effectiveness of an integrated approach to assisting general practitioners (GPs) with diabetes management. This approach uses a centralized database of clinical data of an Australian Division of General Practice (a network of GPs) to co-ordinate care according to national guidelines. METHODS: Long term outcomes for patients in the program were derived using clinical parameters after 5 years of program participation, and the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model, to project outcomes for 40 years from the time of diagnosis and from 5 years postdiagnosis. Cost information was obtained from a range of sources. While program costs are directly available, and costs of complications can be estimated from the UKPDS model, other costs are estimated by comparing costs in the Division with average costs across the state or the nation. The outcome and cost measures are used derive incremental cost-effectiveness ratios. RESULTS: The clinical data show that the program is effective in the short term, with improvement or no statistical difference in most clinical measures over 5 years. Average HbA1c levels increased by less than expected over the 5 year period. While the program is estimated to generate treatment cost savings, overall net costs are positive. However, the program led to projected improvements in expected life years and Quality Adjusted Life Expectancy (QALE), with incremental cost effectiveness ratios of $A8,106 per life-year saved and$A9,730 per year of QALE gained. CONCLUSIONS: The combination of an established model of diabetes progression and generally available data has provided an opportunity to establish robust methods of testing the cost effectiveness of a program for which a formal control group was not available. Based on this methodology, integrated health care delivery provided by a network of GPs improved health outcomes of type 2 diabetics with acceptable cost effectiveness, which suggests that similar outcomes may be obtained elsewhere

Implementing integrated measurements of essential biodiversity variables at a national scale

Funding: the Strategic Science Investment Funding for Crown Research Institutes from the Ministry of Business, Innovation and Employment.1. There is a global need for observation systems that deliver regular, timely data on state and trends in biodiversity, but few have been implemented, and fewer still at national scales. We describe the implementation of measurement of Essential Biodiversity Variables (EBVs) on an 8 km × 8 km grid throughout New Zealand, with multiple components of biodiversity (vegetation, birds, and some introduced mammals) measured simultaneously at each sample point. 2. Between 2011 and 2017, all public land was sampled nationally (ca. 1,350 points) and some private land (ca. 500 points). Synthetic appraisals of the state of New Zealand's biodiversity, not possible previously, can be derived from the first measurement of species distribution, population abundance, and taxonomic diversity EBVs. 3. Native bird counts (all species combined) were about 2.5 times greater per sample point in natural forests and shrublands than in non‐woody ecosystems, and native bird counts exceeded those of non‐native birds across all natural forests and shrublands. 4. Non‐native plants, birds, and mammals are invasive throughout, but high‐rainfall forested regions are least invaded, and historically deforested rain shadow regions are most invaded. 5. National reporting of terrestrial biodiversity across New Zealand's public land is established and becoming normalised, in the same manner as national and international reporting of human health and education statistics. The challenge is extending coverage across all private land. Repeated measurements of these EBVs, which began in 2017, will allow defensible estimates of biodiversity trends.Publisher PDFPeer reviewe

Phase 1-2a multicenter dose-escalation study of ezatiostat hydrochloride liposomes for injection (Telintra®, TLK199), a novel glutathione analog prodrug in patients with myelodysplastic syndrome

<p>Abstract</p> <p>Background</p> <p>Ezatiostat hydrochloride liposomes for injection, a glutathione S-transferase P1-1 inhibitor, was evaluated in myelodysplastic syndrome (MDS). The objectives were to determine the safety, pharmacokinetics, and hematologic improvement (HI) rate. Phase 1-2a testing of ezatiostat for the treatment of MDS was conducted in a multidose-escalation, multicenter study. Phase 1 patients received ezatiostat at 5 dose levels (50, 100, 200, 400 and 600 mg/m²) intravenously (IV) on days 1 to 5 of a 14-day cycle until MDS progression or unacceptable toxicity. In phase 2, ezatiostat was administered on 2 dose schedules: 600 mg/m²IV on days 1 to 5 or days 1 to 3 of a 21-day treatment cycle.</p> <p>Results</p> <p>54 patients with histologically confirmed MDS were enrolled. The most common adverse events were grade 1 or 2, respectively, chills (11%, 9%), back pain (15%, 2%), flushing (19%, 0%), nausea (15%, 0%), bone pain (6%, 6%), fatigue (0%, 13%), extremity pain (7%, 4%), dyspnea (9%, 4%), and diarrhea (7%, 4%) related to acute infusional hypersensitivity reactions. The concentration of the primary active metabolites increased proportionate to ezatiostat dosage. Trilineage responses were observed in 4 of 16 patients (25%) with trilineage cytopenia. Hematologic Improvement-Erythroid (HI-E) was observed in 9 of 38 patients (24%), HI-Neutrophil in 11 of 26 patients (42%) and HI-Platelet in 12 of 24 patients (50%). These responses were accompanied by improvement in clinical symptoms and reductions in transfusion requirements. Improvement in bone marrow maturation and cellularity was also observed.</p> <p>Conclusion</p> <p>Phase 2 studies of ezatiostat hydrochloride liposomes for injection in MDS are supported by the tolerability and HI responses observed. An oral formulation of ezatiostat hydrochloride tablets is also in phase 2 clinical development.</p> <p>Trial Registration</p> <p>Clinicaltrials.gov: NCT00035867</p

Prognostic impact of multidrug resistance gene expression on the management of breast cancer in the context of adjuvant therapy based on a series of 171 patients

Study of the prognostic impact of multidrug resistance gene expression in the management of breast cancer in the context of adjuvant therapy. This study involved 171 patients treated by surgery, adjuvant chemotherapy±radiotherapy±hormonal therapy (mean follow-up: 55 months). We studied the expression of multidrug resistance gene 1 (MDR1), multidrug resistance-associated protein (MRP1), and glutathione-S-transferase P1 (GSTP1) using a standardised, semiquantitative rt–PCR method performed on frozen samples of breast cancer tissue. Patients were classified as presenting low or high levels of expression of these three genes. rt-PCR values were correlated with T stage, N stage, Scarff–Bloom–Richardson (SBR) grade, age and hormonal status. The impact of gene expression levels on 5-year disease-free survival (DFS) and overall survival (OS) was studied by univariate and multivariate Cox analysis. No statistically significant correlation was demonstrated between MDR1, MRP1 and GSTP1 expressions. On univariate analysis, DFS was significantly decreased in a context of low GSTP1 expression (P=0.0005) and high SBR grade (P=0.003), size ⩾5 cm (P=0.038), high T stage (P=0.013), presence of intravascular embolus (P=0.034), and >3 N+ (P=0.05). On multivariate analysis, GSTP1 expression and the presence of ER remained independent prognostic factors for DFS. GSTP1 expression did not affect OS. The levels of MDR1 and MRP1 expression had no significant influence on DFS or OS. GSTP1 expression can be considered to be an independent prognostic factor for DFS in patients receiving adjuvant chemotherapy for breast cancer

Living in Parallel Universes: Physiotherapists and Insurance Workers’ Beliefs in the West Australian Workers’ Compensation System

Objective: This study investigated beliefs related to ‘grey areas’ of in- jured worker management in the West Australian workers’ compen- sation system. Methods: Six common scenarios related directly to the management of injured workers were devised with two main themes of ‘Reason- able Expenses’ and ‘Health Worker Roles’. The scenarios were fo- cused on musculoskeletal disorders. Eighty physiotherapists and 48 insurance workers (case managers, injury management advisors) par- ticipated in an online questionnaire. Level of agreement with each scenario was assessed and opportunity provided for individual com- ments. Results: Differences were identified in the beliefs related to the six scenarios both between and within professions. Both professions had varied opinions as to when treatment under the workers’ com- pensation system should cease. There was a lack of consensus in both professions on the provision of treatment for comorbidity within the system. There were differing opinions between professions re- lated to the role of various stakeholders, with good communication emerging as a common theme to deal with potential role conflicts. Conclusion: This study confirms the existence of a number of ‘grey areas’ directly related to injured worker management in the Western Australian workers’ compensation system. These ‘grey areas’ have the potential to result in inefficiencies, inconsistency in care, confu- sion and frustration for stakeholders