[What is a cost-benefit analysis?].

Purpose It is uncertain whether modest benefits from adjuvant chemotherapy in stage II colorectal cancer justify the toxicity, cost, and inconvenience. We investigated the usefulness of defective mismatch repair (dMMR), BRAF, and KRAS mutations in predicting tumor recurrence and sensitivity to chemotherapy. Patients and Methods Immunohistochemistry for dMMR and pyrosequencing for KRAS/BRAF were performed for 1,913 patients randomly assigned between fluorouracil and folinic acid chemotherapy and no chemotherapy in the Quick and Simple and Reliable (QUASAR) trial. Results Twenty-six percent of 695 right-sided colon, 3% of 685 left-sided colon, and 1% of 407 rectal tumors were dMMR. Similarly, 17% of right colon, 2% of left colon, and 2% of rectal tumors were BRAF mutant. KRAS mutant tumors were more evenly distributed: 40% right colon, 28% left colon, and 36% rectal tumors. Recurrence rate for dMMR tumors was half that for MMR-proficient tumors (11% [25 of 218] v 26% [438 of 1,695] recurred; risk ratio [RR]...

https://ascopubs.org/doi/pdf/10.1200/jco.2010.30.1366

Value of Mismatch Repair, KRAS, and BRAF Mutations in Predicting Recurrence and Benefits From Chemotherapy in Colorectal Cancer

Microsatellite instability as a marker of prognosis and response to therapy: a meta-analysis of colorectal cancer survival data.

Summary Background The diagnosis of hypertension has traditionally been based on blood-pressure measurements in the clinic, but home and ambulatory measurements better correlate with cardiovascular outcome, and ambulatory monitoring is more accurate than both clinic and home monitoring in diagnosing hypertension. We aimed to compare the cost-effectiveness of different diagnostic strategies for hypertension. Methods We did a Markov model-based probabilistic cost-effectiveness analysis. We used a hypothetical primary-care population aged 40 years or older with a screening blood-pressure measurement greater than 140/90 mm Hg and risk-factor prevalence equivalent to the general population. We compared three diagnostic strategies—further blood pressure measurement in the clinic, at home, and with an ambulatory monitor—in terms of lifetime costs, quality-adjusted life years, and cost-effectiveness. Findings Ambulatory monitoring was the most cost-effective strategy for the diagnosis of hypertension for men and women of all ages. It was cost-saving for all groups (from −£56 [95% CI −105 to −10] in men aged 75 years to −£323 [−389 to −222] in women aged 40 years) and resulted in more quality-adjusted life years for men and women older than 50 years (from 0·006 [0·000 to 0·015] for women aged 60 years to 0·022 [0·012 to 0·035] for men aged 70 years). This finding was robust when assessed with a wide range of deterministic sensitivity analyses around the base case, but was sensitive if home monitoring was judged to have equal test performance to ambulatory monitoring or if treatment was judged effective irrespective of whether an individual was hypertensive. Interpretation Ambulatory monitoring as a diagnostic strategy for hypertension after an initial raised reading in the clinic would reduce misdiagnosis and save costs. Additional costs from ambulatory monitoring are counterbalanced by cost savings from better targeted treatment. Ambulatory monitoring is recommended for most patients before the start of antihypertensive drugs. Funding National Institute for Health Research and the National Institute for Health and Clinical Excellence.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)61184-7.pdf

Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study.

'This report gives the latest information on how Aboriginal and Torres Strait Islander people in the Northern Territory are faring according to a range of measures of health status and outcomes, determinants of health and health system performance. Indicators are based on the Aboriginal and Torres Strait Islander Health Performance Framework. The report highlights the main areas of improvement and continuing concern.' - Back cover

http://www.territorystories.nt.gov.au/jspui/bitstream/10070/270343/1/Health%20performance%20frame%20work%20-%20Northern%20Territory.pdf

Aboriginal and Torres Strait Islander health performance framework

Objective: To consider the plausible nutritional impacts of fluctuations in money availability within an income cycle for remote Indigenous Australians.Design: Community-level dietary intake (energy, micro/macronutrients) and expenditure on foods and beverages (F&B) were estimated over one year for three remote Indigenous Australian communities (Northern Territory, Australia) using monthly F&B transaction data. F&B that were likely to be consumed during a period within an income cycle when money was relatively limited (low money period (LMP) foods) were identified by panel consensus and scenario modelling was conducted to simulate the nutritional outcomes of a range of F&B selection responses to having an LMP.Results: All scenarios resulted in reduced diet quality during the LMP relative to overall average diet values. Protein and fat energy percentages were reduced and carbohydrate energy percentage increased. Despite reduced expenditure, declines in energy intake were typically buffered due to the reduced energy cost ($AU/MJ) of the LMP diet. The micronutrient profile of the LMP diet was substantially poorer, such that additional key micronutrients dropped below population-weighted Estimated Average Requirements/Adequate Intakes.Conclusions: The modelling undertaken herein suggests that even a short period of low money within an income cycle may noticeably contribute to the reduced diet quality of remote Indigenous Australians and exacerbate lifestyle disease risk. Dietary strategies that are designed to respond to diets and expenditure during different income cycle periods, rather than the overall average diet and expenditure, should be considered for improving diet quality and reducing cardiometabolic disease risk in remote Indigenous Australians.

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Fluctuations in money availability within an income cycle impacts diet quality of remote Indigenous Australians

This paper describes the patient journey mapping tools and frameworks used in the Managing Two Worlds Together (MTWT) Project. We sought to explore the barriers and enablers, gaps and strategies in relation to country Aboriginal patient journeys from rural and remote locations to city hospitals and return, from the perspective of the patient/client, their carer/ family, and local health care providers.

Managing two worlds together: stage 2 — patient journey mapping tools

If a new drug’s incremental price-effectiveness ratio (IPER) is above the health shadow price, β c , the best alternative strategy to new drug reimbursement will result in more health benefits to the population, for the same financial cost. The historic decision threshold (k) in most countries is likely to be significantly higher that the health shadow price. If a regulator chooses to reject a new drug as a consequence of adopting the lower threshold, firms might make the following threat: At IPERs below k, it will not be financially viable to supply most new drugs to this country. The weight of this threat could be significant, particularly when the new drugs have substantial clinical benefit for some patient groups. How should a rational institution respond? In this chapter, this question is first analysed in a conventional decision theoretic (non-strategic) model as the optimal response by regulators to historic evidence of the price of new drugs. Then the question is analysed within a price-effectiveness analysis (PEA) framework. PEA uses an applied game theoretic model that assumes firms act strategically and that the health of the population, not the target patients, is the maximand. I conclude that the decision to reimburse a new drug is best analysed as a game with multiple players who act strategically and where the objective of the Institution is to maximise the population’s health. The second conclusion is that the population health-maximising response to the threat is to maintain a threshold price of $ \beta $ c.

The “New Drug Reimbursement” Game

As health sector professionals, scientists and academics, we recognise that the health sector must contribute to greenhouse gas (GHG) emission-reduction targets. Audits of the health sector show that, in addition to the “usual suspects” (power, transport and waste), anaesthetic gases and propellants in metered dose inhalers are contributors to health sector GHG emissions [1, 2]. Furthermore, health services and technologies differ in their GHG profiles, therefore decisions between options can have implications for the health sector’s GHG emissions. Health economic evaluations (HEEs) and health technology assessments (HTAs) are often guided by the principle of inclusion rather than exclusion of consequences of value. It would appear inevitable that in the current climate, health economists are considering whether the net impact on GHG emissions should be included routinely in the assessments and evaluations. GHG accounting is not a recent phenomenon and at least some of the preconditions for ensuring an efficient and effective integration of the impact of GHG emissions into HEE/HTA have been met. Methods of accounting for GHG emissions are internationally validated [3] and, like health economic methods, subject to continual review and responsive to changes in evidence. There are strong similarities between the guidelines for calculating GHG emissions for a jurisdiction and the guidelines used by public health sector funders for HEE and HTA, most notably the reliance on evidence. While the question of the value of projected change in GHG emissions arising from a decision is subject to debate, there are established carbon markets and prices in many jurisdictions.1 And GHG emission impacts are already incorporated in numerous decision processes in the public and private sector, including in the UK where the Treasury publishes guidance on how to calculate the cost effectiveness of climate change policies [8]. On face value at least, it appears that HEE/HTA could incorporate impacts of GHG emissions. This raises a number of important questions. What are the practical barriers to integrating GHG emission impacts into HEE/HTA methods? What would a set of “green” HEE/HTA guidelines look like? Would they be costly to implement? Would existing reimbursement processes become more or less at risk of gaming? And are there more effective ways for the health economists to contribute to GHG emission-reduction targets in the health sector?

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The Inclusion of Comparative Environmental Impact in Health Technology Assessment: Practical Barriers and Unintended Consequences.

This publication is one of five that report on the work of the Funding, Accountability and Results (FAR) project, all published by the Lowitja Institute in 2015. The research reported here, in summary form, is a study of reforms in primary health care for Aboriginal and Torres Strait Islander communities in the Northern Territory (between 2009 and 2014) and Cape York, Queensland (between 2006 and 2014). In both places, the intention of the reforms was twofold: to establish a regional system of PHC provision with reliable access to care for all Aboriginal and Torres Strait Islander communities in the regions, and to increase community control of health care by transferring some or most of the responsibility for providing PHC from government health authorities to regional Aboriginal Community Controlled Health Organisations (ACCHOs). These were bold plans with long histories of development in both jurisdictions.

/pdf/the-road-is-made-by-walking-towards-a-better-primary-health-iw85wxqa8j.pdf

Brita Pekarsky

Papers

Fluctuations in money availability within an income cycle impacts diet quality of remote Indigenous Australians

Managing two worlds together: stage 2 — patient journey mapping tools

The “New Drug Reimbursement” Game

The Inclusion of Comparative Environmental Impact in Health Technology Assessment: Practical Barriers and Unintended Consequences.

The road is made by walking: towards a better primary health care system for Australia's first peoples