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Biomedical subjects

Leonie Segal

Publications and source records attributed to Leonie Segal.

13 recordsLinked to original sources
PubMed2006

A population-based model for priority setting across the care continuum and across modalities.

BACKGROUND: The Health-sector Wide (HsW) priority setting model is designed to shift the focus of priority setting away from 'program budgets'--that are typically defined by modality or disease-stage--and towards well-defined target populations with a particular disease/health problem. METHODS: The key features of the HsW model are i) a disease/health problem framework, ii) a sequential approach to covering the entire health sector, iii) comprehensiveness of scope in identifying intervention options and iv) the use of objective evidence. The HsW model redefines the unit of analysis over which priorities are set to include all mutually exclusive and complementary interventions for the prevention and treatment of each disease/health problem under consideration. The HsW model is therefore incompatible with the fragmented approach to priority setting across multiple program budgets that currently characterises allocation in many health systems. The HsW model employs standard cost-utility analyses and decision-rules with the aim of maximising QALYs contingent upon the global budget constraint for the set of diseases/health problems under consideration. It is recognised that the objective function may include non-health arguments that would imply a departure from simple QALY maximisation and that political constraints frequently limit degrees of freedom. In addressing these broader considerations, the HsW model can be modified to maximise value-weighted QALYs contingent upon the global budget constraint and any political constraints bearing upon allocation decisions. RESULTS: The HsW model has been applied in several contexts, recently to osteoarthritis, that has demonstrated both its practical application and its capacity to derive clear evidenced-based policy recommendations. CONCLUSION: Comparisons with other approaches to priority setting, such as Programme Budgeting and Marginal Analysis (PBMA) and modality-based cost-effectiveness comparisons, as typified by Australia's Pharmaceutical Benefits Advisory Committee process for the listing of pharmaceuticals for government funding, demonstrate the value added by the HsW model notably in its greater likelihood of contributing to allocative efficiency.

Journal Article↗
PubMed2006

Parsimonious and efficient assessment of health-related quality of life in osteoarthritis research: validation of the Assessment of Quality of Life (AQoL) instrument.

BACKGROUND: The Assessment of Quality of Life (AQoL) utility instrument was psychometrically developed for the general population. This study aimed to explore its potential as an osteoarthritis (OA) outcome measure. METHODS: WOMAC, Lequesne index, SF-36, Visual analogue scales and the AQoL were administered to 222 people with OA. The ability of each questionnaire to detect differences between groups was based on (i) self-rated health (SRH) and, (ii) differences between people on an orthopedic waiting list (WL) vs people with OA in the community (C). Comparisons included effect size, relative efficiency and receiver operator characteristic curves. RESULTS: All instruments detected differences between groups; however no one instrument exhibited superior efficiency. The AQoL demonstrated strong psychometric properties. CONCLUSION: The AQoL has equivalent performance to comparator questionnaires commonly used in OA research and would be a useful adjunct to well-established disease specific scales. The AQoL has important advantages; brevity (12 items), facilitates comparisons between disease groups, and delivers a utility score that can be used in health economic evaluations.

Aged↗
PubMed2006

A mediterranean diet is cost-effective in patients with previous myocardial infarction.

This evaluation aimed to assess the economic performance of the Mediterranean diet for patients after a first acute myocardial infarction (AMI). A cost utility analysis using a Markov model was used to compare the Mediterranean diet to a prudent Western diet over a time frame of 10 years. After a systematic review of the literature, program effectiveness was based on the Lyon Diet Heart Study (605 patients, mean age 54 y, randomized to the Mediterranean diet delivered by a dietician and cardiologist, or a prudent Western diet). Costs were estimated in AU$ [and converted to US$ and Euros (euro)] based on the resource use to which published unit costs were applied. Cost and benefits were discounted at 5% per annum. The main outcome measure was cost per quality-adjusted life year (QALY) gained. Extensive 1-way sensitivity analyses were performed. The Mediterranean diet compared with a prudent Western diet was estimated to cost AU$1013 (US$703, euro579) per QALY gained per person. There was a mean gain in life years of 0.31/person and a gain in quality-adjusted life years of 0.40/person. Based on the published results from the Lyon Diet Heart Study and conservative assumptions, the Mediterranean diet is highly cost-effective for persons after a first AMI and represents an exceptional return on investment. Policy makers should strongly consider the generalizability of results to their own setting.

Cost-Benefit Analysis↗
PubMed2006

Cost utility analysis of physical activity counselling in general practice.

OBJECTIVE: To evaluate the economic performance of the 'Green Prescription' physical activity counselling program in general practice. METHODS: Cost utility analysis using a Markov model was used to estimate the cost utility of the Green Prescription program over full life expectancy. Program effectiveness was based on published trial data (878 inactive patients presenting to NZ general practice). Costs were based on detailed costing information and were discounted at 5% per anum. The main outcome measure is cost per quality adjusted life year (QALY) gained. Extensive one-way sensitivity analyses were performed along with probabilistic (stochastic) analysis. RESULTS: Incremental, modelled cost utility of the Green Prescription program compared with 'usual care' was dollar NZ2,053 per QALY gained over full life expectancy (range dollar NZ827 to dollar NZ37,516 per QALY). Based on the probabilistic sensitivity analysis, 90% of ICERs fell below dollar NZ7,500 per QALY. CONCLUSIONS: Based on a plausible and conservative set of assumptions, if decision makers are willing to pay at least dollar NZ2,000 per QALY gained the Green Prescription program is likely to represent better value for money than 'usual care'. IMPLICATIONS: The Green Prescription program performs well, representing a good buy relative to other published cost effectiveness estimates. Policy makers should consider encouraging general practitioners to prescribe physical activity advice in the primary care setting, in association with support from exercise specialists.

Adult↗
PubMed2005

Economic evaluation of interventions for problem drinking and alcohol dependence: do within-family external effects make a difference?

AIMS: To propose methods for the inclusion of within-family external effects in clinical and economic evaluations. To demonstrate the extent of bias due to the exclusion of within-family external effects when measuring the relative performance of interventions for problem drinking and alcohol dependence. METHODS: The timing and magnitude of treatment effects are modified to accommodate the external health-related quality of life impact of having a problem or dependent drinker in the family home. RESULTS: The inclusion of within-family external effects reduces cost per QALY estimates of interventions for problem drinking and alcohol dependence thereby improving the performance of all evaluated interventions. In addition, the inclusion of within-family external effects improves the relative performance of interventions targeted at those with moderate-to-severe alcohol dependence as compared to interventions targeted at less severe alcohol problems. CONCLUSIONS: Failure to take account of external effects in clinical and economic evaluations results in an uneven playing field. Interventions with readily quantifiable health benefits (where social costs and benefits are predominantly comprised of private costs and benefits) are at a distinct advantage when competing for public funding against interventions with quantitatively important external effects.

Alcohol Drinking↗
PubMed2005

Economic evaluation of interventions for problem drinking and alcohol dependence: cost per QALY estimates.

AIMS: To compare the performance of competing and complementary interventions for prevention or treatment of problem drinking and alcohol dependence. To provide an example of how health maximising decision-makers might use performance measures such as cost per quality adjusted life year (QALY) league tables to formulate an optimal package of interventions for problem drinking and alcohol dependence. METHODS: A time-dependent state-transition model was used to estimate QALYs gained per person for each intervention as compared to usual care in the relevant target population. RESULTS: Cost per QALY estimates for each of the interventions fall below any putative funding threshold for developed economies. Interventions for problem drinkers appear to offer better value than interventions targeted at those with a history of severe physical dependence. CONCLUSIONS: Formularies such as Australia's Medicare should include a comprehensive package of interventions for problem drinking and alcohol dependence.

Adolescent↗
PubMed2004

Can we reduce disease burden from osteoarthritis?

The comparison of disparate interventions for the prevention and management of osteoarthritis (OA) is limited by the quality and quantity of published efficacy studies and the use of disparate measures for reporting clinical trial outcomes. The "transfer to utility" technique was used to translate published trial outcomes into a health-related quality-of-life (utility) scale, creating a common metric which supported comparisons between disparate interventions. Total hip replacement (THR) and total knee replacement (TKR) surgery were the most effective treatments and also highly cost-effective, at estimated cost per quality-adjusted life-year (QALY) of 7500 dollars for THR and 10000 dollars for TKR (best estimate). Other apparently highly cost-effective interventions were exercise and strength training for knee OA (< 5000 dollars/QALY), knee bracing, and use of capsaicin or glucosamine sulfate (< 10000 dollars/QALY). The cost per QALY estimates of non-specific and COX-2 inhibitor non-steroidal anti-inflammatory drugs were affected by treatment-related deaths and highly sensitive to the discounting of life-years lost. OA interventions that have been shown to be ineffective (eg, arthroscopy) are targets for redistribution of healthcare resources. OA interventions which lack efficacy studies (eg, prevention programs) require further research to assist priority setting. The application of the Health-sector Wide model to OA demonstrates its role as an evidence-based model that can be successfully applied to identify marginal interventions - those to be expanded and contracted to reduce the expected burden of disease, within current healthcare resources.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2004

Introducing co-ordinated care (1): a randomised trial assessing client and cost outcomes.

A program of care co-ordination (CC) in Melbourne for individuals with a history of high use of in-patient services was evaluated. The intervention involved care planning by a general practitioner (GP) and graduated case management depending on client health status. Services were purchased from pooled funds of participating health care agencies. A randomised control trial of 2,742 participants demonstrated no significant differences between the intervention and usual care group for two quality of life measures, the SF-36 and the AQoL (assessment of quality of life), and no difference in mortality rates. Total resource usage in the CC group was substantially higher, principally due to the extra costs for care planning and case management and for administering the CC model. Results conform to the higher costs typically found in other CC trials, although the failure to demonstrate improved client outcomes is less often reported. The reasons for this failure, whether in trial design, implementation, or theoretical underpinnings are explored in a companion paper.

Adolescent↗
PubMed2004

Introducing coordinated care (2): evaluation of design features and implementation processes implications for a preferred health system reform model.

The study investigated why the goals of the Australian Coordinated Care trials for clients with complex care needs were not achieved. Significantly higher health service use and costs were incurred in the absence of clear evidence of improved client health outcomes. The validity of assumptions underpinning trial design and the success of implementation at each step in application of the model were examined. There were failures in both design and implementation. Many clients did not require care coordination. The funds pooling arrangements contributed to limited possibilities for service substitution and training of GP care coordinators was inadequate. Trial design did not focus on either clinical guidelines or consumer empowerment. Furthermore, the expectations of the overall national trial were unrealistic both in trial design and expected outcomes given the rigidities and realities of the Australian health care system. Broader system reform in the form of funds pooling and health services planning at the regional level, based on large populations, may be a more effective means to address problems of care coordination and an inflexible supply system.

Australia↗
PubMed2004

Private health insurance and the Pharmaceutical Benefits Scheme: how effective has recent government policy been?

The cost to government of the Pharmaceutical Benefits Scheme (PBS) is rising at over 10 percent per annum. The government subsidy to Private Health Insurance (PHI) is about $2.4 billion and rising. Despite this, the queues facing public patients - which were the primary justification for the assistance to PHI - do not appear to be shortening. Against this backdrop, we seek to evaluate recent policies. It is shown that the reason commonly given for the support of PHI - the need to preserve the market share of private hospitals and relieve pressure upon public hospitals - is based upon a factually incorrect analysis of the hospital sector in the last decade. It is similarly true that the 'problem' of rising pharmaceutical expenditures has been exaggerated. The common element in both sets of policies is that they result in cost shifting from the public to the private purse and have little to do with the quality or quantity of health services.

Financing, Government↗
PubMed2004

Why it is time to review the role of private health insurance in Australia.

The role of private health insurance (PHI) within the Australian health-care system is urgently in need of comprehensive review. Two decades of universal health cover under Medicare have meant a change in the function of PHI, which is not reflected in policies to support PHI nor in the public debate around PHI. There is increasing evidence that the series of policy adjustments introduced to support PHI have served to undermine rather than promote the efficiency and equity of Australia's health care system. While support for PHI has been justified to 'take pressure off the public hospital system' and to facilitate choice of insurer and private provider', and the incentives have indeed increased PHI membership, this increase comes at a high cost relative to benefits achieved. The redirection of hospital admissions from the public to private hospitals is small, with a value considerably less than 25% of the cost of the policies. The Commonwealth share of the health care budget has increased and the relative contribution from private health insurance is lower in 2001-02, despite an increase in PHI membership to nearly 45% of the population, compared with the 30% coverage in 1998. The policies have largely directed subsidies to those on higher incomes who are more likely to take out PHI, and to private insurance companies, private hospitals and medical specialists. Ad hoc policy adjustments need to be replaced by a coherent policy towards PHI, one that recognises the fundamental change in its role and significance in the context of universal health coverage.

Australia↗
PubMed2002

Strengths and limitations of competitive versus non-competitive models of integrated capitated fundholding.

Integrated budget-holding (fundholding) based on risk-adjusted capitation is commonly proposed as a central element of health system reform. Two contrasting models have been developed: the competitive model where fundholders or health plans compete for enrollees; and the non-competitive model, where plan membership is determined according to an objective attribute such as place of residence. Under the competitive model, efficiency is sought through consumer choice of plan. A range of regulatory elements may also be introduced to moderate undesirable elements of competition. Under the non-competitive model, efficiency is achieved through government regulation and the fact that the fundholder has continuing responsibility for the health of a defined population, supported by micro-management tools (such as quality assurance and selective payment arrangements). In theory, the non-competitive model encourages population-based health services planning. While both models assume risk-adjusted capitated funding, the requirements of any formula are more stringent under the competitive model. Economic theory, as well as documented health system experience, can help identify the relative strengths and limitations of each model. Concerns with the competitive model relate primarily to the capacity to develop robust risk adjusters for capitation sufficient to reduce the incentives for patient risk selection. Possible reductions in the quality of care are also a concern, compounded by difficulties for consumers in discriminating between plans. Efficiency under the non-competitive model requires a strong and appropriate regulatory/policy framework and effective use of micro-management tools. Funding equity objectives can be met through either model by the adoption of income-related contributions, but under the competitive model this may be compromised by incentives for the fundholders to select low-risk patients. Evidence drawn from regional fundholding in New South Wales (NSW, Australia), the US Veterans Health Agency and the literature on managed care in the USA illustrate these concerns. The problem of risk selection in the competitive model is a major theoretical concern, confirmed by the empirical evidence. This, together with concerns regarding other aspects of performance, suggests that the non-competitive model may be preferable, at least as an interim step in reform in public or mixed systems. Future research on this issue is clearly required.

Competitive Medical Plans↗