Decision making by patients: An application of naturalistic decision making theory to cervical screening and chronic renal failure, Working Paper 2006/5

Over their lifetime, individuals typically make many decisions about health and health care. Theoretical approaches to decision making have been dominated by a rational, analytic approach which assumes that problems are relatively fixed and well-defined and which have foreseeable and measurable endpoints. Naturalistic decision making (NDM) approaches attempt to mimic ?real world? situations where problems vary, may be defined differently by individuals with diverse perspectives and where endpoints are uncertain and complicated. In-depth interviews were conducted with 40 individuals living in the community: twenty participants had chronic renal failure and twenty were women in the target age range for cervical cancer screening. Decision making processes used by these two groups of health care consumers correspond well with the concepts of NDM. In particular, Image Theory provides a framework within which the process of decision making by health care consumers can be described, including the issues which influence what decisions are made. The findings also demonstrate the usefulness of studying decision making in ?real world? situations and in using less analytic techniques than traditional normative approaches in evaluating health care decision making. The results suggest that NDM is deserving of a wider audience in health care. Health care providers who use NDM models to understand their patients? decision making processes may improve their capacity to involve patients in decision making.Decision making, cervical screening

Economic analysis of Tai Chi as a means of preventing falls and falls related injuries among older adults, CHERE Working Paper 2006/4

This study has examined the costs and consequences of a randomised controlled trial of a community based Tai Chi program for people over 60 years of age. The hypothesis for the trial was that compared to non-participants, participants in the Tai Chi program would have fewer falls and may experience additional health and other benefits. In terms of resource use it was anticipated that the Tai Chi program would use additional resources in terms of running costs but was expected to save resources as a result of falls prevented. Data for this economic evaluation were collected prospectively alongside the randomised controlled trial. The aim of this evaluation was to investigate the cost-effectiveness of Tai Chi as means of preventing falls in elderly people living in the community. Costs included were those of the Tai Chi trial and health service utilisation (including GP and specialist and other consultations, tests, hospitalisations and medications). Effectiveness was measured as the number of participants in the intervention and control groups, all participants and the number of falls avoided. SPSS was used to analyse the data; Fisher?s exact and the student?s t-test were used to test differences between the intervention and control groups. From the perspective of NSW Health, the cost of providing Tai Chi as part of this trial ($81232) outweighed any costs of health service provision ($24795). Only a small proportion used health services and this mostly involved the use of over-the-counter pain relieving medication and GP consultations. Only 3 people were admitted to hospital. There were no significant differences between the study and control groups in terms of utilisation and costs except in terms of overall costs where the control group costs were significantly more than the study group (p=0.43). However, this difference was driven by the cost of one admission to hospital. In the trial 3/216 falls resulted in hospitalisation. This means that for every 100 falls avoided, 1.4 serious falls were prevented. Assuming that Tai Chi would continue to prevent falls at the same rate as the trial, 740 individuals would need to participate in Tai Chi to avoid 100 falls and 1.4 serious falls. The value of avoiding a small number of serious falls must be weighed against the high cost of treating and managing the consequences of such falls.Tai chi, economic aspects, Australia

Evaluation of directional vacuum-assisted breast biopsy: Report for the National Breast Cancer Centre final report, CHERE Project Report No 21

This project was commissioned by the National Breast Cancer Centre (NBCC). The objectives of the project, as set out in the call for expressions of interest, were to determine: 1. The costs associated with the introduction and use of directional vacuum-assisted breast biopsy(DVA breast biopsy) in Australia; and 2. Whether directional vacuum-assisted breast biopsy used for diagnostic purposes is cost-effectivein Australia when compared to core biopsy. The motivation for commissioning the project was an assessment of directional vacuum-assisted breast biopsy conducted by the Medical Services Advisory Committee (MSAC) which concluded that the procedure is safe and more effective than core biopsy. Although a cost-effectiveness analysis was not conducted as part of the MSAC study, MSAC recommended that the costs associated with the procedure be investigated and that, pending a review of costs, the procedure receive interim Medicare funding at a higher level than was previously available. For the project reported here, data was required to be collected from both public and private sectors on the cost of introducing and using DVA breast biopsy and a cost-effectiveness analysis (CEA) conducted on the introduction and use of DVA breast biopsy with and without a prone table. The research question for the CEA was What is the impact on costs and number of open biopsies performed of using DVA breast biopsy compared to core biopsy for micro-calcification lesions? It is important to note that this question specifies both the outcome the CEA (change in the number of core biopsies performed) and that the investigation was to be confined to micro-calcification lesions only. An expert multidisciplinary working group was assembled to oversee the project. Following collection of data an interim report was produced for the working group. As DVABB is a relatively new technology in Australia the interim report indicated that the current number of sites performing DVABB and the level of experience of users was insufficient to provide meaningful data to achieve the project aims. On the advice of the working group it was agreed to suspend the project at this juncture. The NBCC will consider repeating the survey in the future.Breast cancer, diagnostics, breast biopsy, Australia

No difference in cost-effectiveness of intensive group training for chronic back pain compared with usual physiotherapy care

QuestionIs an intensive group training protocol costeffective compared to usual care physiotherapy for chronic low back pain?DesignEconomic evaluation alongside a randomised controlled trial comparing two physiotherapy interventions for chronic low back pain.SettingPrimary care physiotherapy clinics in and around Amsterdam, the Netherlands, involving 85 physiotherapists.Participants114 participants with a new episode of non-specific low back pain of more than 12 weeks duration and aged 18 to 65 years were included. Patients with specific spinal pathology were excluded.InterventionsParticipants in the intensive group performed 10 individual and 20 group sessions consisting of graded exercises and back school based on behavioural principles. Those allocated to usual care received an average of 9 sessions of individual physiotherapy treatments according to the Royal Dutch College for Physiotherapy Low Back Pain Guidelines.OutcomesTreatment effectiveness was measured using the following pre-specified outcomes: functional status (24-item Roland-Morris Disability Questionnaire), pain intensity (11-point numerical rating scale), general perceived effect (6-point GPE scale) and quality of life (EuroQol-5D) at baseline, 6, 13, 26, and 52 weeks after randomisation, with 89% followup at 1 year. Diaries were used to measure costs associated with utilisation of health care, non-health care, medications, and loss of productivity due to work absenteeism. Multilevel analyses were performed to determine the difference in effects. The mean differences in costs between groups and 95% confidence intervals (CIs) were obtained by bias corrected and accelerated bootstrapping. Quality of life was expressed in utilities based on the Dutch tariff.ResultsThe differences in effects were small and not significant. Although the direct health care costs were higher for the intensive training group, (between-group difference per patient €233, 95% CI 2185 to 2764), there were no differences between the groups in terms of total health costs.ConclusionThe intensive group training protocol is not cost-effective compared with usual care physiotherapy carried out according to the guidelines. Whilst there is no clinical contraindication to the use of the intensive group training program, the results do not support implementation of the intensive program for back pain in primary care in the Netherlands

A qualitative insight into rural casemix education, CHERE Project Report No 10

NSW, while often regarded as the non- Casemix state, has been using Casemix information to assist planning and funding of hospitals. However, the use of this tool and the necessary education and knowledge about Casemix has not been evenly spread throughout the state, with health service staff in metropolitan areas relatively more familiar with its use then their colleagues in rural NSW. In 1998, both NSW Health and the NSW Casemix Clinical Committee (NCCC) proposed that an effort be made to increase the knowledge and participation of rural clinical and health service staff in Casemix activities. This research was proposed as a means of establishing the current situation regarding Casemix, knowledge in rural areas, providing advice regarding the best methods of implementing Casemix education for rural staff and, if possible, evaluating the success of the education. Casemix is a broad term referring to the tools and information system used to assist in such activities as planning, benchmarking, managing and funding health care services. Casemix is underpinned by classification systems that allow meaningful comparisons of workload or throughput between facilities. In this study, qualitative research methods were used to examine the issues faced by rural health service staff in gaining knowledge of and using Casemix. This information was supplemented by a survey, which assessed the level of knowledge and understanding of Casemix in two rural areas.Casemix, hospital funding

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

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

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

A Markov model of Diabetic Retinopathy Progression for the Economic Evaluation of a novel DR prognostic device, CHERE Working Paper 2007/14

The initial diagnosis of Diabetic Retinopathy (DR) is often in the advance stages of the condition, as patients are only promoted for an examination when sight has been affected. An innovative prognostic technique has recently been made available which can non-invasively detect the damaging effects of high blood glucose before the development of clinical symptoms. This innovation offers the opportunity to patients to make the necessary behavioural and medicinal modification to prevent further progress of the disease. This paper reports the development of a Markov model which emulates the natural progression of Diabetic Retinopathy based on data from clinical trials. The purpose of such a model is to estimate the chronic cost and health outcomes of DR, and it may be modified to reflect the potential changes in current practice or condition changes, hence allowing for an economic evaluation of the DR prognostic test. The implications and limitations of the model were also discussed in the paper.Diabetic retinopathy, economic evaluation

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

Hospital in the home, NSW