Objective. Pressure injuries (PI) are largely preventable and can be viewed as an adverse outcome of a healthcare admission, yet they affect millions of people and consume billions of dollars in healthcare spending. The existing literature in Australia presents a patchy picture of the economic burden of PI on society and the health system. The aim of the present study was to provide a more comprehensive and updated picture of PI by state and severity using publicly available data.Methods. A cost-of-illness analysis was conducted using a prevalence approach and a 1-year time horizon based on data from the existing literature extrapolated using simulation methods to estimate the costs by PI severity and state subgroups.Results. The treatment cost across all states and severity in 2012-13 was estimated to be A$983 million per annum, representing approximately 1.9% of all public hospital expenditure or 0.6% of the public recurrent health expenditure. The opportunity cost was valued at an additional A$820 million per annum. These estimates were associated with a total number of 121 645 PI cases in 2012-13 and a total number of 524 661 bed days lost.Conclusions. The costs estimated in the present study highlight the economic waste for the Australian health system associated with a largely avoidable injury. Wastage can also be reduced by preventing moderate injuries (Stage I and II) from developing into severe cases (Stage III and IV), because the severe cases, accounting for 12% of cases, mounted to 30% of the total cost. What is known about the topic?The literature has identified that in the Australian health care system, wound management is one of the most frequently performed procedures. However, the overall economic cost of PI to the public hospital system is largely unknown. What does this paper add? This study provides reliable estimates, based predominantly on Australian data, of the number of cases and treatment costs associated with PI in public hospitals, disaggregated by state and severity. The paper also attempts to quantify the opportunity cost of PI, which leads to extra hospital length of stay. The estimated costs give an indication of the economic waste to the health system due to avoidable injury. What are the implications for practitioners? This study is relevant and important in the context of rising healthcare costs. It highlights an area for potential improvement in quality of care (i.e. better hospital experience for patients) and efficiency (i.e. reducing economic waste) in the hospital sector. It also reveals the paucity of data available to support cost estimation, from the prevalence and incidence rates to the treatment cost by disease severity, which further highlights an under-researched area.

Indigenous Australians experience a high rate of ear disease and hearing loss, yet they have a lower rate of service access and utilisation compared to their non-Indigenous counterparts. Screening, surveillance and timely access to specialist ear, nose and throat (ENT) services are key components in detecting and preventing the recurrence of ear diseases. To address the low access and utilisation rate by Indigenous Australians, a collaborative, community-based mobile telemedicine-enabled screening and surveillance (MTESS) service was trialled in Cherbourg, the third largest Indigenous community in Queensland, Australia. This paper aims to evaluate the cost-effectiveness of the MTESS service using a lifetime Markov model that compares two options: (i) the Deadly Ears Program alone (current practice involving an outreach ENT surgical service and screening program), and (ii) the Deadly Ears Program supplemented with the MTESS service. Data were obtained from the Deadly Ears Program, a feasibility study of the MTESS service and the literature. Incremental cost-utility ratios were calculated from a societal perspective with both costs (in 2013–14 Australian dollars) and quality-adjusted life years (QALYs) discounted at 5% annually. The model showed that compared with the Deadly Ears Program, the probability of an acceptable cost-utility ratio at a willingness-to-pay threshold of $50,000/QALY was 98% for the MTESS service. This cost effectiveness arises from preventing hearing loss in the Indigenous population and the subsequent reduction in associated costs. Deterministic and probability sensitivity analyses indicated that the model was robust to parameter changes. We concluded that the MTESS service is a cost-effective strategy. It presents an opportunity to resolve major issues confronting Australia’s health system such as the inequitable provision and access to quality healthcare for rural and remotes communities, and for Indigenous Australians. Additionally, it may encourage effective health service delivery at a time when the healthcare funding and workforce capacity are limited.

Although both pharmacotherapy and rTMS are clinically effective treatments for major depressive disorder, rTMS is shown to outperform antidepressants in terms of cost-effectiveness for patients who have failed at least two adequate courses of antidepressant medications.

BackgroundTo evaluate a Geriatric Emergency Department Intervention (GEDI) model of service delivery for adults aged 70 years and older.MethodsA pragmatic trial of the GEDI model using a pre-post design. GEDI is a nurse-led, physician-championed, Emergency Department (ED) intervention; developed to improve the care of frail older adults in the ED. The nurses had gerontology experience and education and provided targeted geriatric assessment and streamlining of care. The final format included 2.4 full time equivalent nurses working 7 days from 0700 h to 1730 h (1530 h at weekends). There were three implementations periods: pre-implementation (2012); a developmental phase from January 2013 to August 2015; and full implementation from September 2015 to August 2016. The outcomes measured were disposition (discharged home, admitted or died); ED length of stay; hospital length of stay; all cause in-hospital mortality within 28 days; time to ED re-presentation up to 28 days post-discharge; in-hospital costs.The setting was a tertiary hospital ED, with 385 beds, in Queensland, Australia. Approximately 53,000 patients presented to the ED annually with 20% aged 70 years and older. All patients over the age 70 who presented to the ED between January 2012 and August 2016 (n = 44,983) were included in the trial.ResultsOlder persons who presented to the ED when the GEDI team were working had increased likelihoods of discharge (Hazard ratio (HR) = 1.19; 95% CI: 1.13–1.24) and reduced ED length of stay (HR = 1.42; 95% CI: 1.33–1.52) compared with those who presented when GEDI were not working. There was no increase in the risk of mortality (HR = 1.01; 95% CI = 0.23–4.43) or risk of same cause re-presentation to 28 days (HR = 1.21; 95% CI: 0.99–1.49). The GEDI service resulted in average cost savings per ED presentation of $35 [95% CI, $21, $49] and savings of $1469 [95% CI, $1105, $1834] per hospital admission.ConclusionsImplementation of a nurse-led physician-championed model of ED care, focused on frail older adults, reduced ED length of stay, hospital admission and if admitted, hospital length of stay and cost, without increasing mortality or same cause re-presentation. These increases were sustained over time and after the initial implementation team had changed roles.Trial registrationAustralian Clinical Trials Registration Number ACTRN12615001157561 - retrospectively registered on 29/10/2015. Data were retrieved via retrospective access to clinical information systems. First data access was on 1/7/2015.

BackgroundRecent assessments show continued decline in child mortality in Papua New Guinea (PNG), yet complete subnational analyses remain rare. This study aims to estimate under-five mortality in PNG at national and subnational levels to examine the importance of geographical inequities in health outcomes and track progress towards Millennium Development Goal (MDG) 4.MethodologyWe performed retrospective data validation of the Demographic and Health Survey (DHS) 2006 using 2000 Census data, then applied advanced indirect methods to estimate under-five mortality rates between 1976 and 2000.FindingsThe DHS 2006 was found to be unreliable. Hence we used the 2000 Census to estimate under-five mortality rates at national and subnational levels. During the period under study, PNG experienced a slow reduction in national under-five mortality from approximately 103 to 78 deaths per 1,000 live births. Subnational analyses revealed significant disparities between rural and urban populations as well as inter- and intra-regional variations. Some of the provinces that performed the best (worst) in terms of under-five mortality included the districts that performed worst (best), with district-level under-five mortality rates correlating strongly with poverty levels and access to services.ConclusionsThe evidence from PNG demonstrates substantial within-province heterogeneity, suggesting that under-five mortality needs to be addressed at subnational levels. This is especially relevant in countries, like PNG, where responsibility for health services is devolved to provinces and districts. This study presents the first comprehensive estimates of under-five mortality at the district level for PNG. The results demonstrate that for countries that rely on few data sources even greater importance must be given to the quality of future population surveys and to the exploration of alternative options of birth and death surveillance.

BackgroundThe probability of survival through childhood continues to be unequal in middle-income countries. This study uses data from the Philippines to assess trends in the prevalence and distribution of child mortality and to evaluate the country’s socioeconomic-related child health inequality.MethodologyUsing data from four Demographic and Health Surveys we estimated levels and trends of neonatal, infant, and under-five mortality from 1990 to 2007. Mortality estimates at national and subnational levels were produced using both direct and indirect methods. Concentration indices were computed to measure child health inequality by wealth status. Multivariate regression analyses were used to assess the contribution of interventions and socioeconomic factors to wealth-related inequality.FindingsDespite substantial reductions in national under-five and infant mortality rates in the early 1990s, the rates of declines have slowed in recent years and neonatal mortality rates remain stubbornly high. Substantial variations across urban-rural, regional, and wealth equity-markers are evident, and suggest that the gaps between the best and worst performing sub-populations will either be maintained or widen in the future. Of the variables tested, recent wealth-related inequalities are found to be strongly associated with social factors (e.g. maternal education), regional location, and access to health services, such as facility-based delivery.ConclusionThe Philippines has achieved substantial progress towards Millennium Development Goal 4, but this success masks substantial inequalities and stagnating neonatal mortality trends. This analysis supports a focus on health interventions of high quality – that is, not just facility-based delivery, but delivery by trained staff at well-functioning facilities and supported by a strong referral system – to re-start the long term decline in neonatal mortality and to reduce persistent within-country inequalities in child health.

This review finds that the EuroQol five-dimension questionnaire is the most valid utility-based instrument for people with dementia, but should be replaced by others under certain circumstances. Although no utility estimates were reported in the article, the meta-regression analyses that examined variations in utility estimates produced by different instruments impact on cost-utility analysis, potentially altering the decision-making process in some circumstances.

No abstract