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Introduction While the evidence of mental health benefits from investing in green space accumulates, claims of reduced healthcare expenditure are rarely supported by evidence from analyses of actual healthcare data. Additionally, the question of ‘who pays?’ has been ignored. We addressed these gaps using person-level data in three Australian cities. Methods 55,339 participants with a mean follow-up time of 4.97 years in the Sax Institute's 45 and Up Study (wave 2, collected 2012–2015) were linked to fee-for-service records of antidepressant prescriptions and talking therapy subsidised by the Australian Government (including data on per unit fee, state subsidy, and individual co-payment). Total green space, tree canopy and open grass within 1.6 km road network distances were linked to each participant. Multilevel logistic, negative binomial, and generalised linear models with gamma distribution adjusted for demographic and socioeconomic confounders were used to assess association between each green space variable and prescribing/referral and costs of antidepressants and talking therapy. Results Prescription of at least one course of antidepressants occurred for 20.01% (n = 11,071). Referral for at least one session of talking therapy occurred in 8.95% (n = 4954). 13,482 participants (24.4%) had either a prescription or a referral. A 10% increase in green space was associated with higher levels of antidepressant prescribing (e.g. incident rate ratio (IRR) = 1.06, 95%CI = 1.04–1.08). Tree canopy was not associated with antidepressant prescribing or referrals for talking therapy. Open grass was associated with higher odds (OR = 1.17, 95%CI = 1.13–1.20) and counts (IRR = 1.05, 95%CI = 1.02–1.08) of antidepressant prescriptions. Open grass was also associated with lower odds (OR = 0.87, 95%CI = 0.82–0.92) and counts (IRR = 0.93, 95%CI = 0.90–0.96) of talking therapy referrals. Open grass was associated with higher total and mean per-person levels of expenditure on antidepressant prescriptions. Conclusion Although green space supports mental health, these unexpected results provide pause for reflection on whether greening strategies will always result in purported reductions in mental healthcare expenditure.

Successful health promotion and disease prevention strategies in complex community settings such as primary schools rely on acceptance and ownership across community networks. Assessing multiplier impacts from investment on related community activity over time are suggested as key alongside evidence of program health effects on targeted groups of individuals in gauging community network engagement and ownership, dynamic impacts, and program long term success and return on investment. An Australian primary school based health promotion and prevention strategy, the Stephanie Alexander Kitchen Garden National Program (SAKGNP), which has been providing garden and kitchen classes for year 3–6 students since 2008, was evaluated between 2011 and 2012. Returns on Australian Federal Government investment for school infrastructure grants up to $60,000 are assessed up to and beyond a two year mutual obligation period with: (i) Impacts on student lifestyle behaviours, food choices and eating habits surveyed across students (n = 491 versus 260) and parents (n = 300 versus 234) in 28 SAKGNP and 14 matched schools, controlling for school and parent level confounders and triangulated with SAKGNP pre-post analysis; (ii) Multiplier impacts of investment on related school and wider community activity up to two years; and (iii) Evidence of continuation and program evolution in schools observed beyond two years. SAKGNP schools showed improved student food choices (p = 0.024) and kitchen lifestyle behaviour (p = 0.019) domains compared to controls and in pre-post analysis where 20.0% (58/290) reported eating fruit and vegetables more often and 18.6% (54/290) preparing food at home more often. No significant differences were found in case control analysis for eating habits or garden lifestyle behaviour domains, although 32.3% of children helped more in the garden (91/278) and 15.6% (45/289) ate meals together more often in pre-post analysis. The multiplier impact on total community activity up to two years was 5.07 ($226,737/$44,758); 1.60 attributable to school, and 2.47 to wider community, activity. All 8 schools observed beyond two years continued garden and kitchen classes, with an average 17% scaling up and one school fully integrating staff into the curriculum. In conclusion evidence supports the SAKGNP to be a successful health promotion program with high community network impacts and return on investment in practice.

Objectives Formative evaluation is critical in maximising the implementation strategies and processes of interventions. It is also critical to both providing contextual explanations for and maximising the success of such interventions. The purpose of this study was to undertake a comprehensive formative evaluation of the implementation process of a multi-component, sports-based mental health program for adolescent males (“Ahead of the Game”). Methods Primary outcomes included program reach, dose, fidelity and cost during initial piloting and two distinct implementation phases. The iterative formative evaluation process provided opportunities to adapt the program and its implementation strategy to optimise reach, dose and fidelity relative to implementation cost. Results Formative evaluation data showed that the program failed to achieve optimal reach in the initial pilot phase (Phase I), with low doses of the program received by stakeholders, and moderate fidelity. Bottom up implementation strategies improved dose and club ownership during Phase II but resulted in high costs and lower fidelity and was associated with implementation staff retention and management issues. Phase III with more streamlined staffing and club integrated implementation resulted in high reach, dose, fidelity and club ownership and an associated reduction in implementation cost per participant. Conclusion : Formative evaluation succeeded in maximising the Ahead of the Game program engagement over three distinct phases. Results are salient for informing cost-effective implementation strategies for sports-based health promotion.

Evidence based medicine supports net benefit maximising therapies and strategies in processes of health technology assessment (HTA) for reimbursement and subsidy decisions internationally. However, translation of evidence based medicine to practice is impeded by efficiency measures such as cost per case-mix adjusted separation in hospitals, which ignore health effects of care. In this paper we identify a correspondence method that allows quality variables under control of providers to be incorporated in efficiency measures consistent with maximising net benefit. Including effects framed from a disutility bearing (utility reducing) perspective (e.g. mortality, morbidity or reduction in life years) as inputs and minimising quality inclusive costs on the cost-disutility plane is shown to enable efficiency measures consistent with maximising net benefit under a one to one correspondence. The method combines advantages of radial properties with an appropriate objective of maximising net benefit to overcome problems of inappropriate objectives implicit with alternative methods, whether specifying quality variables with utility bearing output (e.g. survival, reduction in morbidity or life years), hyperbolic or exogenous variables. This correspondence approach is illustrated in undertaking efficiency comparison at a clinical activity level for 45 Australian hospitals allowing for their costs and mortality rates per admission. Explicit coverage and comparability conditions of the underlying correspondence method are also shown to provide a robust framework for preventing cost-shifting and cream-skimming incentives, with appropriate qualification of analysis and support for data linkage and risk adjustment where these conditions are not satisfied. Comparison on the cost-disutility plane has previously been shown to have distinct advantages in comparing multiple strategies in HTA, which this paper naturally extends to a robust method and framework for comparing efficiency of health care providers in practice. Consequently, the proposed approach provides a missing link between HTA and practice, to allow active incentives for evidence based net benefit maximisation in practice.

Objective: When undertaking indirect comparisons, relative risk (RR) is often suggested as an appropriate indicator of treatment effect, particularly where baseline (common comparator) risks differ. In this article, we demonstrate that such use of RR in indirect comparisons is not necessarily stable with respect to framing of outcomes. Study Design and Setting: Use of RR is shown to lead to inferential fallacies where, for example, a new therapy is suggested to reduce both mortality and survival risk. Conditions under which the inferential fallacy arises and an odds solution are illustrated in indirect comparison of natalizumab and interferon beta-1b for multiple sclerosis. Results: Using RR, natiluzimab is suggested to be 30% more effective than interferon for progression (RR = 0.70), but 16% less effective than interferon for no progression (RR = 0.84). This inferential anomaly is avoided using odds ratios (ORs), with odds of progression (0.83) the reciprocal of that for no progression (1.21). Conclusion: Inferential fallacies with use of RR in indirect comparison provide scope for abuse with respect to choice in framing of outcomes, and confound decision making where both results are presented. The use of ORs overcomes this inferential fallacy, consistently informing inference with respect to direction of treatment effect in indirect comparisons.

BACKGROUND: We compared cost-effectiveness of pravastatin in a placebo-controlled trial in 5500 younger (31-64 years) and 3514 older patients (65-74 years) with previous acute coronary syndromes. METHODS: Hospitalizations and long-term medication within the 6 years of the trial were estimated in all patients . Drug dosage, nursing home, and ambulatory care costs were estimated from substudies. Incremental costs per life saved of pravastatin relative to placebo were estimated from treatment effects and resource use. RESULTS: Over 6 years, pravastatin reduced all-cause mortality by 4.3% in the older patients and by 2.3% in the younger patients. Older patients assigned pravastatin had marginally lower cost of pravastatin and other medication over 6 years (A dollar 4442 vs A dollar 4637), but greater cost offsets (A dollar 2061 vs A dollar 897) from lower rates of hospitalizations. The incremental cost per life saved with pravastatin was A dollar 55500 in the old and A dollar 167200 in the young. Assuming no treatment effect beyond the study period, the life expectancy to age 82 years of additional survivors was 9.1 years in the older and 17.3 years in the younger. Estimated additional life-years saved from pravastatin therapy were 0.39 years for older and 0.40 years for younger patients. Incremental costs per life-year saved were A dollar 7581 in the older and A dollar 14944 in the younger, if discounted at 5% per annum. CONCLUSIONS: Pravastatin therapy was more cost-effective among older than younger patients, because of their higher baseline risk and greater cost offsets, despite their shorter life expectancy.

Value of information (VOI) methods allow decision makers to identify efficient trial design following a principle of maximising the expected value to decision makers of information from potential trial designs relative to their expected cost. In health technology assessment these methods have been applied to identify optimal trial designs within jurisdiction where decision makers face positive but uncertain incremental net benefit. However, previous applications in HTA have ignored new information arising outside of jurisdiction, implicitly making the restrictive assumption that there is only expected value from research commissioned within a jurisdiction. This paper relaxes this restrictive assumption to extend the framework and methods for optimal trial design and decision making within jurisdiction in Eckermann and Willan (2007) to allow for optimal trial design across jurisdictions. A principle of maximising the expected global value of non-rival information less expected costs of trial designs optimally allocated across jurisdictions allows identification of optimal decision making within jurisdictions and optimal trial design across jurisdictions. For non-rival trial information, estimates of expected value of sample information (EVSI) for each jurisdiction conditional on prior incremental net benefit (INB) and the context of adoption or delay are able to be summed across jurisdiction. Direct and opportunity costs of trial design can be minimised in allocating trial sample across jurisdictions. These principles and methods are illustrated in identifying optimal trial design for decision making across North America, the UK and Australia in the case of early versus late external cephalic version. The expected net gain (ENG) of locally optimal trial designs of US$0.72 million is shown to increase to US$1.14 million with optimal trial design across these jurisdictions. In general, the proposed method of global optimal trial design is shown to improve on optimal trial design within jurisdictions by: (i) Reflecting the global value of non-rival information; (ii) Allowing optimal allocation of trial sample across jurisdiction; (iii) Avoiding sub-optimal spreading of fixed costs and heterogeneity of trial information with multiple trials and; (iv) Permitting adoption and trial (AT) in jurisdictions with expected positive net clinical benefit, without AT being infeasible or unethical. Consequently, provided evidence can be translated across jurisdictions, optimal global trial design following the identified principles and methods increases ENG from any set of locally optimal trial designs. Eckermann S, Willan A. Expected Value of Information and Decision Making in HTA. Health Economics 16:195-209 (2007).