An economic evaluation of the prison methadone program in New South Wales, CHERE Project Report No 22

Objectives - The aim of this study is to evaluate the costs and consequences of the provision of the prison methadone program in NSW, compared with no prison methadone. Methods - This study has measured the costs involved in the provision of the prison methadone program in NSW. The overall cost of the prison methadone program was estimated from a governmental perspective, incorporating the costs associated with the administration of the program, staffing requirements, methadone syrup and consumables. Both bottom-up and top-down costing approaches have been used. Both the total cost of the program and the cost per inmate in treatment are presented. The study is based on a follow-up study of a randomised trial of prison methadone in the NSW prison system (Dolan, Shearer et al. 2003). Although methadone is available to prisoners in many NSW prisons, the aim of the trial was to determine the impact of prison methadone on a range of health and social outcomes. Participants were randomised to receive prison methadone immediately or to be waitlisted. Waitlisted inmates were offered methadone after a four month delay. The cohort recruited by Dolan et al is now the subject of a four year follow-up study. Since all subjects had been offered methadone at the conclusion of the RCT, this could no longer be treated as controlled study. This limits the utility of the study outcome data for the economic evaluation. In the absence of comparative outcome data, a threshold analysis has been performed to determine what magnitude of outcomes is required to render the prison methadone program cost-neutral from a governmental perspective. The threshold analysis assumes that, through the provision of prison methadone, patients will gain from the benefits associated with continuous methadone treatment. Thus future criminal activity will be reduced and re-incarceration may be avoided. The analysis determines how many days of re-incarceration must be avoided to offset the annual cost of the methadone program. Firstly the analysis estimates what additional resources are required in the prison system to deliver prison methadone. Secondly, potential cost savings associated with avoided re-incarceration are estimated. The costs of the prison methadone program are then compared with the cost savings accrued by avoided days of re-incarceration and the level of effectiveness required to equate costs and savings is identified. A second threshold analysis assumes that, in addition to avoiding days of re-incarceration, prison methadone also avoids incident cases of Hepatitis-C. Given the cost of the program and the number of avoided cases of Hepatitis-C, the threshold analysis identifies the level of effectiveness, in terms of avoided re-incarceration, at which methadone treatment becomes cost neutral. Results - The total cost of providing prison methadone to 900 inmates in 21 prisons in NSW is $2.9million per annum. The cost per person year is$3,234. Given that the average daily cost of incarceration is $176, the annual cost of prison methadone is offset by avoiding 20 days of re-incarceration once the inmate is released. If avoided incident cases of hepatitis-C are included in the analysis, the annual cost of prison methadone is offset by avoiding 19 days of re-incarceration once the inmate is released. Conclusions - This analysis shows that, despite significant barriers to efficiency, prison methadone compares favourably to community based methadone on the basis of cost alone. The analyses suggests that, irrespective of whether avoided cases of Hepatitis-C are included, approximately 20 days of reincarceration must be avoided to offset the annual cost of methadone treatment. There appears to be no evidence in the literature to prove or disprove the feasibility of prison methadone maintenance avoiding such a period of re-incarceration.Methadone, eonomic evaluation

Health care policy evaluation: empirical analysis of the restrictions implied by Quality Adjusted Life Years, CHERE Working Paper 2006/10

This paper investigates the nature of the utility function for health care, defined over the probability of survival, survival duration, health state and cost of treatment. A discrete choice experiment, involving treatment choice for a hypothetical health condition is used to test restrictions on preferences in the QALY model. We find that preferences do not conform to expected utility, and there are significant interactions between health state and survival duration. Individual characteristics are significant, implying substantial differences in valuations of health states across the population. The results suggest the QALY approach distorts valuations of health outcomes.Discrete choice experiment, Qalys, preferences, health state valuation

Does the reason for buying health insurance influence behaviour? CHERE Working Paper 2006/1

The inter-relationship between private health insurance cover and hospital utilisation is complex. The current policy approach in Australia appears to rely on relatively simple models of the relationships between health insurance coverage, and public and private hospital use. There is considerable evidence of unexplained heterogeneity among the privately insured population. Heterogeneity of preferences is likely to be important not just in determining the uptake of private health insurance, but also the impact of changes in private health insurance on the use of private treatment. A number of studies have used attitudinal variables to model heterogeneity of preferences in other contexts. This study uses the 2001 ABS National Health Survey to identify ?types? among the insured population using their stated reasons for purchasing private health insurance. We find that insurance type is significantly associated with hospital utilisation, particularly the probability of being admitted as a public or private patient. We also find that the government?s insurance incentives were more attractive to particular types of the insured population. This has implications for the effectiveness of the insurance incentives and for the design of policies that aim to reduce pressure on the public hospital system.Private health insurance, health policy, Australia

General Practitioners knowledge, views and practices regarding cervical cancer screening in Australia. CHERE Working Paper 2010/6

Objective General practitioners (GPs) are the main providers of cervical screening in Australia and are crucial to the successful implementation of the National Cervical Screening Program (NCSP). This study assesses the views of GPs about the value of the Pap smear tests, their knowledge of the current screening policy, awareness of new technologies and concerns of litigation. Design A postal survey was conducted of a random sample of GPs in New South Wales, Australia. Results GPs are generally supportive of NCSP guidelines, specifically 88.5% now agree with the recommended 2 year screening interval. However, half believe the age range should be enlarged to include both older and younger patients. There are notable differences in knowledge and views between male and female GPs. Female GPs tend to support extending the age range and are more familiar with new technologies, whilst male GPs are more concerned about the legal implications of over and under-screening patients. Conclusions While the NCSP is generally well supported by GPs, there are differences in the knowledge and views of male and female GPs. This information provides a contemporary baseline from which to optimise the effectiveness of GPs as providers of cervical screening, improve the rate of appropriate utilisation and successfully implement any future changes to the national screening guidelines.GPs, Cervical cancer screening, Australia

Patients? perceptions of the value of PET in diagnosis and management of non-small call lung cancer, CHERE Working Paper 2007/5

A randomized controlled trial comparing the use of PET versus no PET provided the opportunity to investigate the value patients placed on any additional information provided by the PET scan. Interviews were undertaken with patients after their diagnosis had been made and, in the case of those who had surgery, once they had returned home following the operation. Content analysis was used to describe and analyse the text of the interviews. The aims of the research were to explore with people receiving PET their perceptions of its impact on aspects of well being, acquire a better understanding of how patients understand and deal with the outcomes (both benefits and dis-benefits) of PET, and assess the decision making processes regarding PET and subsequent treatment (surgical and non-surgical) from the patients? perspectives with the aim of providing information which can be used by providers of care in improving the process of care. Interviews were conducted with a sub-sample of 59 trial participants between February 2000 and July 2001, between six and eight weeks post-surgery. Thirty-three, (56%) had received a PET scan and 26 (44%) had not. The majority of patients consulted a surgeon in the expectation of having surgery to remove their cancer. Participants viewed PET (along with the other tests) as being most likely to provide information and reassurance to the surgeon, rather than having any impact on their (patients?) decisions. As far as these participants were concerned, there was only one important decision - whether to have surgery - and that decision was in the hands of the surgeon. All other decisions were subordinate to this major milestone and thus did not appear significant to patients. Thus, on its own, PET appeared to be of little additional value to this group of patients. Between 23%-45% of respondents reported some complications whilst in hospital or some difficulties at home but these were mostly of a relatively minor nature. Even though some patients reported that their health was worse than when they entered hospital, most participants reported that their health was improving at the time of the interview. Most participants had, at least briefly, discussed the issue of relapse with a doctor at a consultation subsequent to their surgery. The diagnosis of cancer is the key issue; all that happens to them subsequently seems to be determined by clinicians. It is important that clinicians explain the reasons for tests such as PET to patients and use diagnostic tests appropriately in the management of the disease. Understanding the experiences of patients provides useful information for clinicians in preparing patients for surgery for lung cancer and for cancer services in considering the level of ongoing support required for patients following surgery.Positron emission tomography, lung cancer

Hospital in the Home in NSW, CHERE Project Report No 16

Hospital in the home, NSW

Evaluation of participants' experiences with a non-restrictive minimally-structured lifestyle intervention. CHERE Working Paper 2010/11

While there is increasing evidence that group-based lifestyle-focussed interventions may provide more realistic, effective and cost-effective alternatives to intensive, individualised dietary counselling and exercise training, relatively little is known about individuals? preferences for and perceptions of these programs. This paper reports the results of qualitative interviews conducted with participants of a lifestyle intervention trial (Shape up for Life? (SufL) aimed to improve body composition and metabolic health through long-term non-restrictive behaviour modification. Purposive sampling was used to identify 22 participants who participated in detailed interviews regarding their expectations of the intervention, perceptions of benefits and their experience post-intervention and capacity to maintain the lifestyle changes. The results indicate that in general participants are focussed on weight loss as a goal, even when the intervention offered and provided other benefits such as improved fitness and body shape and composition. The individuals who benefited most from the intervention typically had lower baseline knowledge about dietary and exercise guidelines. While the relatively non-restrictive nature of SufL provided flexibility for participants, many participants perceived that a more structured program may have assisted in achieving weight loss goals.Obesity, lifestyle intervention, weight loss, metabolic syndrome

Consultancy to progress hospital in the home care provision: Final report, CHERE Project Report No 13

In July 1998, the Commonwealth Department of Health and Family Services commissioned the Centre for Health Economics Research and Evaluation (CHERE) to identify and document Hospital in the Home (HITH) care models nationally and internationally. The purpose of this consultancy was to examine the appropriateness of this form of care for acutely ill patients and to make recommendations about how to increase the utilisation and cost effectiveness of services. Hospital in the Home is emerging internationally and within Australia as a viable alternative form of provision of acute care. The benefits of HITH have generally been seen in terms of its capacity to provide a cost-effective and acceptable alternative to hospital inpatient care, which reduces pressure on hospital beds. However, so far there has only been limited evaluation to lend support to these claims. Over the past decade a wide range of hospital in the home programs have been introduced across the Australian health care system. These programs have often emerged in response to local factors and have a range of different purposes, funding and organisational arrangements, and varying levels of success. In some states hospital in the home has been formalised into a program, whereas in other parts of Australia the introduction of HITH has been left to local decision makers. Thus, the experience of HITH has been extremely variable. It is appropriate at this stage to draw together information about what services are available, how acceptable these services are and what they have achieved. This information is important for determining the future directions of HITH in Australia, as well as providing a valuable resource for service providers and policy makers.Hospital in the home, Australia

Decisions about Pap tests: What influences women and providers?

Despite the success internationally of cervical screening programs debate continues about optimal program design. This includes increasing participation rates among under-screened women, reducing unnecessary early re-screening, improving accuracy of and confidence in screening tests, and determining the cost-effectiveness of program parameters, such as type of screening test, screening interval and target group. For all these issues, information about consumer and provider preferences and insight into the potential impact of any change to program design on consumer and provider behaviour are essential inputs into evidence-based health policy decision making. This paper reports the results of discrete choice experiments to investigate women?s choices and providers? recommendations in relation to cervical screening in Australia. Separate experiments were conducted with women and general practitioners, with attributes selected to allow for investigation of interaction between women?s and providers? preferences and to determine how women and general practitioners differ in their preferences for common attributes. The results provide insight into the agency relationship in this context. Our results indicate a considerable commonality in preferences but the alignment was not complete. Women put relatively more weight on cost, chance of a false positive and if the recommended screening interval were changed to one year.Cervical Screening; Discrete choice experiments; Agency relationships, Consumer preferences

Evaluating changes in women's attitudes towards cervical screening following a screening promotion campaign and a free vaccination program. CHERE Working Paper 2009/3

This study examines behavioural changes brought about by two interventions introduced to lower the incidence of cervical cancer in Australia. The first intervention is a media campaign promoting regular screening behaviour to women. The second intervention is a vaccination program providing a free HPV vaccine, Gardasil, to young women launched in the same period. The results using data from discrete choice experiments find that in general, given individual characteristics, the interventions have minor impact on how women value screening attributes. The interventions however alter women?s inherent taste for screening. Unexpectedly, willingness to screen is generally lower post-interventions. The reason for this trend appears to be related to HPV events. For instance, the reduction in screening participation is particularly marked among young women who are eligible for the vaccination program. There is also a larger aversion towards testing among women who gained information on HPV facts and HPV-related measures. Thus, in the face of HPV innovations, screening promotions need to account for these factors. A simulation exercise is then performed to assess the plausibility of several strategies to increase the screening rate. The results nominate supply-side policies, in particular those targeted to health providers, as the most effective strategy.cervical screening, HPV Vaccine, preferences, discrete choice experiment, Australia