Equity weights for economic evaluation: An Australian Discrete Choice Experiment, CHERE Working Paper 2008/5

Background: Economic evaluation of healthcare interventions and technologies using the quality-adjusted life year (or life year) usually values outcomes independently of who they accrue to. This is a simplifying assumption relating to the more complex societal preferences. While the premise of equal value has been criticised as being unreflective of societal views, no alternative has gained significant traction. Aims: To identify the trade-offs made by an Australian population between total gain in life expectancy, initial life expectancy, gender, income and smoking status, and then to generate equity weights for economic evaluation from these results. Method: A discrete choice experiment was used in an online panel. 241 respondents answered twelve binary choices, and the results were analysed using logistic regression. Equity weights were then generated using Hicksian compensating variation. Results: A typical individual was willing to discriminate based on smoking and income, but not on gender or initial life expectancy (although the last of these is considered within a narrow range of 55-75 years). However, there was considerable heterogeneity in respondents. Equity weights ranged from 0.673 for smokers with an above average income to 1.207 for non-smokers with a below average income. This result was sensitive to the point at which the marginal utility of time was estimated. Conclusion: Healthcare decision making, using an orthodox QALY model, does not capture the views of society, particularly with regard to smoking or income. We have presented an alternative approach, weighting outcomes dependent on the personal characteristics of the individual receiving them. The feasibility of including this finding in economic evaluation is as yet uncertain and has to be investigated further.Economic evaluation, discrete choice experiment

Access to High Cost Medicines in Australian Hospitals

In the public hospital sector in Australia there is no dedicated scheme to offset costs associated with high cost medications (HCMs) to the institution or the public. (1) Concerns exist as to the equity of access and appropriate mechanisms to manage access to HCMs in public hospitals. (2) There are gaps in the literature as to how decisions are made, and in particular, decision-making processes by which ethical, clinical and economic considerations maybe taken into account. To date, limited work has been conducted regarding the use and funding of HCMs in public hospitals. There are no published data on perceptions, concerns and attitudes, among health care decision-makers or among the community-at-large about access to HCMs in public hospitals. The research reported in this thesis describes the decision-making process and criteria used by health care decision-makers to allocate resources to HCMs in public hospitals. The investigation triangulated quantitative and qualitative methods used to collect and analyse data. Four studies were conducted to describe the decision-making process and explore the perceptions, concerns and attitudes of health care decision-makers and the perceptions of members of the general public regarding access to HCMs in public hospitals. The first study, reported in Chapter Three, was a review of individual patient use (IPU) requests for non-formulary HCMs. This study showed that these requests had a significant impact on the capped expenditure of a public hospital. Subsequent to this review, a new policy and procedure for managing requests for HCMs for IPU was established. A high-cost drugs subcommittee (HCD-SC) operating under the auspices of the Drug and Therapeutics Committee (DTC) was created. The second study, reported in Chapter Four, described the operations of the newly formed HCD-SC. This study also evaluated the decision-making process using the ethical framework “accountability for reasonableness”. (3) Different factors were involved in decisions about access to HCMs and decisions were not solely based on effectiveness and cost. HCD-SC members considered it was important to have consistency in the way decisions were being made. The evaluation of this process allowed identification of good practices and gaps which were considered as opportunities for improvement. The third study, reported in Chapter Five, found that health care decision-makers in an Area Health Service echoed the concerns and agreed about the problems associated with access to HCMs expressed by the HCD-SC members. These studies concluded that the majority of decision-makers wanted an explicit, systematic process to allocate resources to HCMs. These studies also identified tensions between funding systems and hospital decision-making. According to participants there were no mechanisms in place to systematically capture, analyse and share the lessons learned between the macro level (ie. Federal, Pharmaceutical Benefits Scheme - PBS) and the meso level (ie. Institution, public hospital) regarding funding for HCMs. Furthermore, decision-makers considered there are strong incentives for cost-shifting between the Commonwealth and the States. Health care decision-makers also acknowledged the importance of public participation in decision-making regarding allocation of resources to HCMs in public hospitals. However the results of these studies showed that those decisions were not generally made in consultation with the community. Decision-makers perceived that the general public does not have good general knowledge about access to HCMs in public hospitals. A survey of members of the general public, reported in Chapter Six, was then conducted. The survey aimed to gather information about the knowledge and views of members of the general public about access to HCMs in public hospitals. Results of this fourth study showed that respondents had good general knowledge but were poorly informed about the specifics of funding of hospitals and HCMs in private and public hospitals. The results also offered support for the development of a process to involve community members in discussion on policy on the provision of treatment and services within health care institutions and specifically, to seek the views of members of the public on the provision of HCMs and expensive services within public hospitals. In summary, the research reported in this thesis has addressed the gaps in the literature as to how decisions are made, and in particular, the decision-making process and criteria used by health care decision-makers to allocate resources to HCMs in public hospitals. In a move towards more explicitness in decision-making regarding the allocation of scarce health care resources, the findings from these studies provide an evidence base for developing strategies to improve decision-making processes regarding access to HCMs the public sector

Evidence for funding, organising and delivering health care services targeting secondary prevention and management of chronic conditions. CHERE Working Paper 2009/6

This paper is designed as an issues paper. Its aim is to set out what evidence is available regarding the effectiveness and efficiency of funding, organisation and delivery of services directed at preventing and managing chronic conditions, and identify what further information is required. The latter will then be used as a means of identifying gaps in information which can be addressed by research. The information is not presented as a comprehensive review of all available evidence but as a preliminary scoping of the results of the most recent literature.chronic conditions, prevention, funding

Pharmacists\u27 satisfaction with their work: Analysis of an alumni survey

Background: The level of job satisfaction among practicing pharmacists is important because it has been found to affect job performance and employee turnover. The Swedish pharmacy market has undergone major changes in recent years, and little is known about pharmacists’ job satisfaction. Objectives: The objective of this study was to investigate the level of job satisfaction and associated factors among graduates from the web-based pharmacy programs at Umeå University. Methods: Job satisfaction of pharmacists was measured as part of an alumni survey conducted with those who graduated from the pharmacy programmes between 2006 and 2014. Data analysis included descriptive statistics, and logistic regression was used to explore factors affecting job satisfaction. Results: The total number of graduates who completed the survey was 222 (response rate 43%.) The majority of respondents were female (95%), and most were employed at a community pharmacy (85%). The mean age was 39.7 years. The majority of graduates (91%) were satisfied with their job “most of the time” or “all of the time”, and 87% of the respondents would “definitely” or “maybe” choose the same career again. The multivariate analysis showed that increasing years in the current position (OR:0.672 (0.519–0.871)) was associated with lower job satisfaction. Older age (OR: 1.123 (1.022–1.234)), the perception that the knowledge and skills acquired during the education is useful in the current job (OR: 4.643 (1.255–17.182)) and access to continuing professional development (OR:9.472 (1.965–45.662)) were associated with higher job satisfaction. Conclusion: Most graduates from the web-based pharmacy programmes are satisfied with their current job. Access to continuing professional development seems to be important for the level of job satisfaction among pharmacists

Parents\u27 ability to access community health occupational therapy services in a disadvantaged area: A proof of concept study

Introduction: In New South Wales children from disadvantaged backgrounds have poorer health outcomes and reduced access to health services than their more advantaged counterparts. This study aimed to identify barriers and enablers to accessing child and family occupational therapy services in a disadvantaged area. Methods: This was a mixed methods study that included: 1) a retrospective analysis of de-identified routinely collected Community Health service utilisation data from 2016-2017, and a 2) face to face interview guided survey with parents and carers. Results: The retrospective data analysis showed outreach at the targeted suburbs’ Early Childhood Health Centres (ECHC) improved attendance for families living in these suburbs. Overall parents’ reports indicated that they were able to access the Community Health Centre (CHC) however, certain barriers to accessing the service remain, including difficulty parking and not having a license or car to attend appointments. Low health literacy was also a barrier to accessing health appointments as parents were unaware of the range of services provided at CHC, did not know how to make appointments, or that these services did not generate out-of-pocket expenses to clients. Conversely, enablers that would make it easier for parents to attend appointments include the provision of home visits, after hours and weekend appointments, and outreach such as delivering services in community spaces such as the ECHCs, library, or mosque. Conclusion: This research suggests that outreach occupational therapy services are valued by families in this disadvantaged area and contribute towards improving access to allied health services for disadvantaged families with young children. However, additional work is required to increase awareness among disadvantaged families on the role of allied health in improving child development outcomes and to reduce some of the transport and logistical issues that can reduce access to health care

Reducing the use of ineffective health care interventions. CHERE Working Paper 2010/5

This report covers international and Australian models for reducing the use of ineffective interventions, also described as disinvestment. Disinvestment is a development of Health Technology Assessment (HTA). Conventionally HTA has focussed on the introduction of new technologies. Although medical technology is advancing rapidly, there remain very many technologies in use which have not been subject to formal HTA. This has stimulated a growing interest in disinvestment. This review identified a number of case studies and pilot projects. There is limited information available on the mechanisms used, and no rigorous evaluations of their impact. The most developed model is that of NICE which has recently embarked on providing guidance for disinvestment. A number of technologies have been reviewed;but there is limited information available on how these were identified, how disinvestment is implemented, or what the effect has been. There is substantial resistance to any active disinvestment. Across the various case studies, appraisal of candidate technologies seems most likely to be triggered by expert opinion. In Australia, disinvestment is also generally passive. Technologies may be removed from funding or reimbursement if new research demonstrating harms or inefficacy becomes public. More generally, technologies fall into disuse, and are gradually replaced by new or improved technologies. Even when guidelines or funding rules are changed, there is generally continued use of an existing technology. This review has found that active disinvestment has generally been removal of funding for ineffective and/or unsafe technologies, usually initiated by new evidence of inefficacy or harm. Disinvestment is more likely to be passive, ie driven by changes in medical practice, as a procedure or treatment gradually falls out of use over time. There are very few instances of disinvestment, or appraisal for disinvestment, driven by considerations of cost-effectiveness. There are considerable difficulties implementing disinvestment in ineffective health care practices. One area of difficulty is an appropriate mechanism for identifying candidate technologies for appraisal. No explicit processes were identified, although there are a number of published criteria for prioritising candidates. The US is embarking on a major new program of HTA, termed Comparative Effectiveness Research. The list of priority topics for appraisal was developed by the Institute of Medicine, using nominations from health professionals, consumer advocates, policy analysts and others. The development of the candidate topics was a major exercise in itself. Studies of medical practice variations can also be used to identify candidate topics for appraisal. To date, there has been relatively little systematic investigation into practice variations in Australia. The availability of rich data sets which allow analysis on the basis of small areas is essential to research in this field, as is the research capacity to allow rigorous analysis. Program Budgeting and Marginal Analysis is a technique which uses HTA methods to drive disinvestment and reinvestment. It is a relatively resource-intensive activity, and requires clinicians to identify activities for disinvestment. Another area of difficulty arises because there are few or no incentives for clinicians in disinvestment. Thus reinforces the problems of identifying technologies for appraisal. As disinvestment will create losses, to clinicians, to consumers and to providers of the technology, there will be strong resistance to any active withdrawal of funding. At the same time, the additional benefits and/or savings from any disinvestments may not be realised for a considerable period of time and there is a risk that, for some products,interventions or services, cost savings, in particular, may not be realised. This increases the cost of pursuing disinvestment. Both HTA and disinvestment can be seen in a much broader context, that is the challenge is to ensure that the additional health spending brings commensurate benefits ? ensuring health system efficiency. Although there is considerable interest in disinvestment, there are problems in identifying which technologies should be considered for disinvestment, and strong incentives to retain existing technologies. Disinvestment does occur, but generally as a result of existing treatments or other interventions falling into disfavour. An alternative approach to proactive disinvestment of specific technologies is to encourage more rapid change in medical practice. There are various strategies for health care reform which can be categorised as changing provider information, such as through the use of clinical guidelines, or the results of practice variations studies; changing incentives, though different payments for clinicians and other providers, or specifically targeted incentives; changing consumer behaviour, by providing more information with or without financial incentives; or changing the structures of health service delivery to provide organisational support and incentives for more efficient purchasing of care.Disinvestment, Health Technology Assessment, Ineffective health care interventions

What influences chronic pain management? A best–worst scaling experiment with final year medical students and general practitioners

Background: Chronic pain education is an essential determinant for optimal chronic pain management. Given that attitudes and preferences are involved in making treatment decisions, identifying which factors are most influential to final year medical students’ and general practitioners’ (GPs) chronic pain management choices is of importance. This study investigates Swedish and Australian students’ preferences with respect to a chronic pain condition, using a best–worst scaling (BWS) experiment, which is designed to rank alternatives. Methods: BWS, a stated-preference method grounded in random utility theory, was used to explore the importance of factors influencing chronic pain management. Results: All three cohorts considered the patients’ pain description and previous treatment experience as the most important factors in making treatment decisions, whereas their demographics and voices or facial expressions while describing their pain were considered least important. Factors such as social support, patient preferences and treatment adherence were, however, disregarded by all cohorts in favour of pain assessment factors such as pain ratings, description and history. Swedish medical students and GPs show very high correlation in their choices, although the GPs consider their professional experience as more important compared to the students. Conclusion: This study suggests that the relative importance of treatment factors is cemented early and thus underline the critical importance of improving pain curricula during undergraduate medical education

Who enrols and graduates from web-based pharmacy education - Experiences from Northern Sweden

Introduction: As a response to the shortage of prescriptionists in Northern Sweden, a web-based Bachelor of Science in Pharmacy program was introduced at Umeå University in 2003. This study explored who is likely to enrol and graduate from the web-based bachelor program and whether the program has addressed the shortage of prescriptionists in rural Northern Sweden. Methods: Data from three different sources were included in this study; the initial cohort including students admitted to the program in 2003 (survey), the entire cohort including all people admitted to the program between 2003 and 2014 (university\u27s admissions data) and the alumni cohort including graduates who participated in an alumni survey in 2015. Results: A typical student of the web-based pharmacy program is female, over 30 years of age, married or in a de-facto relationship and has children. Furthermore, the students graduating before 2009 were more likely to live in Northern Sweden compared to those graduating later. Discussion and conclusion: The results indicate that the introduction of a web-based bachelor of pharmacy program at Umeå University was to some extent able to address the shortage of prescriptionists in Northern Sweden. Web-based education may potentially help address the maldistribution of health professionals by providing flexible education opportunities

Differences in Swedish and Australian medical student attitudes and beliefs about chronic pain, its management, and the way it is taught

Background and aims: Medical students receive training in the management of chronic pain, but the training is often suboptimal. Considering that the basis for physician’s knowledge is their medical education, it is important to explore the attitudes and beliefs of medical students with respect both to chronic pain management and to their views on current pain education. Therefore, the aim of this study was to compare Swedish and Australian medical student’s attitudes and beliefs about patients with chronic pain, and their perceptions regarding their chronic pain management education. Methods: An online survey was conducted with final year Australian and Swedish medical students from two different universities between December 2016 and February 2017. Attitudes and beliefs towards chronic pain patients were measured using the Health Care Providers’ Pain and Impairment Scale (HC-PAIRS). A thematic analysis was conducted on open end questions regarding their views on their education and important skills for chronic pain management. Results: A total of 57 Swedish and 26 Australian medical students completed the HC-PAIRS scale. The Swedish medical students showed statistically significantly lower total mean HC-PAIRS scores compared to Australian medical students (46 and 51, respectively). Australian students had statistically significantly higher scores than the Swedish students for two of four factors: functional expectations and need for cure, whereas no significant differences were seen for the factors social expectations or for projected cognition. From the open end questions it was evident that final year medical students are knowledgeable about key chronic pain items described in clinical guidelines. However, both cohorts described their chronic pain training as poor and in need of improvement in several areas such as more focus on the biopsychosocial model, working in multidisciplinary teams, seeing chronic pain patients and pharmacological training. Conclusions: Attitudes and beliefs are formed during medical education, and our study exploring attitudes of medical students towards chronic pain and how it is taught have provided valuable information. Our survey provided detailed and cohesive suggestions for education improvement that also are in line with current clinical guidelines. This study indicates that the Swedish final year students have a more positive attitude towards chronic pain patients compared to their Australian counterparts. The majority of students in both cohorts perceived chronic pain management education in need of improvement. Implications: This study highlights several areas of interest that warrant further investigation, for example, the impact of a changed medical curriculum in alignment with these clinical guidelines requested by students in this survey, and correspondingly if their attitudes towards chronic pain patients can be improved through education. Further, we conclude that it would be valuable to align the implementation of the HC-PAIRS instrument in order to achieve comparable results between future studies

Perceptions of shared care among survivors of colorectal cancer from non-English-speaking and English-speaking backgrounds: A qualitative study

Background: Colorectal cancer (CRC) survivors experience difficulty navigating complex care pathways. Sharing care between GPs and specialist services has been proposed to improve health outcomes in cancer survivors following hospital discharge. Culturally and Linguistically Diverse (CALD) groups are known to have poorer outcomes following cancer treatment but little is known about their perceptions of shared care following surgery for CRC. This study aimed to explore how non-English-speaking and English-speaking patients perceive care to be coordinated amongst various health practitioners. Methods: This was a qualitative study using data from face to face semi-structured interviews and one focus group in a culturally diverse area of Sydney with non-English-speaking and English-speaking CRC survivors. Participants were recruited in community settings and were interviewed in English, Spanish or Vietnamese. Interviews were recorded, transcribed, and analysed by researchers fluent in those languages. Data were coded and analysed thematically. Results: Twenty-two CRC survivors participated in the study. Participants from non-English-speaking and English-speaking groups described similar barriers to care, but non-English-speaking participants described additional communication difficulties and perceived discrimination. Non-English-speaking participants relied on family members and bilingual GPs for assistance with communication and care coordination. Factors that influenced the care pathways used by participants and how care was shared between the specialist and GP included patient and practitioner preference, accessibility, complexity of care needs, and requirements for assistance with understanding information and navigating the health system, that were particularly difficult for non-English-speaking CRC survivors. Conclusions: Both non-English-speaking and English-speaking CRC survivors described a blend of specialist-led or GP-led care depending on the complexity of care required, informational needs, and how engaged and accessible they perceived the specialist or GP to be. Findings from this study highlight the role of the bilingual GP in assisting CALD participants to understand information and to navigate their care pathways following CRC surgery