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Ex post moral hazard arises when the insured has an unobservable influence on the size of a loss after its occurrence. In automobile (property) insurance, ex post moral hazard could increase in the scope of the repairs and/or the value of the repairs. Both vehicle owners and auto repairers could gain from increasing the scope of repairs, while auto repairers would gain from an increase in the value of repairs. An analysis of 994 Australian road traffic crashes found that ex post moral hazard increased the value of repairs by 46.8 per cent of which 9 percentage points was explained by an increase in the scope of the repairs, which was defined as an increased from 2 to 2.4 parts per auto repair.

Background This study aims to investigate the impact of multidisciplinary Saturday rehabilitation (MSR) on length of stay, functional independence, gait and balance when compared to a 6-day physiotherapy-only service in a pragmatic setting. An economic evaluation of the intervention conducted from the perspective of the healthcare provider is included.Methods A prospective cohort study with a historical control was conducted in an Australian private mixed rehabilitation unit to compare a multidisciplinary and physiotherapy-only 6-day rehabilitation service. Clinical outcomes included the Functional Independence Measure (Motor, Cognitive, Total), gait speed (10 Meter Walk test) and five balance measures (Timed Up and Go test, Step test, Functional Reach, Feet Together Eyes Closed and the Balance Outcome Measure of Elder Rehabilitation). Economic outcomes were rehabilitation unit length of stay and additional treatment costs.Results A total of 366 patients were admitted to the rehabilitation unit over two 20-week periods. The prospective cohort (MSR) had 192 participants and the historical control group (physiotherapy Saturday rehabilitation) had 174 participants). Participants in the historical control group had lower total and cognitive Functional Independence Measure scores (p Conclusions Implementation of MSR results in a more efficient service, enabling a greater amount of therapy to be provided over a shorter length of stay. The provision of a multi-disciplinary Saturday rehabilitation is potentially cost reducing for the treating hospital.Trial registration not applicable.

IntroductionYoung children with bilateral cerebral palsy (BCP) often experience difficulties with gross motor function, manual ability and posture, impacting developing independence in daily life activities, participation and quality of life. Hand Arm Bimanual Intensive Training Including Lower Extremity (HABIT-ILE) is a novel intensive motor intervention integrating upper and lower extremity training that has been developed and tested in older school-aged children with unilateral and BCP. This study aims to compare an adapted preschool version of HABIT-ILE to usual care in a randomised controlled trial.Methods and analysis60 children with BCP aged 2–5 years, Gross Motor Function Classification System (GMFCS) II–IV will be recruited. Children will be stratified by GMFCS and randomised using concealed allocation to either receive Preschool HABIT-ILE or usual care. Preschool HABIT-ILE will be delivered in groups of four to six children, for 3 hours/day for 10 days (total 30 hours). Children receiving Preschool HABIT-ILE be provided a written home programme with the aim of achieving an additional 10 hours of home practice (total dose 40 hours). Outcomes will be assessed at baseline, immediately following intervention and then retention of effects will be tested at 26 weeks. The primary outcome will be the Peabody Developmental Motors Scales–Second Edition to evaluate gross and fine motor skills. Secondary outcomes will be gross motor function (Gross Motor Function Measure-66), bimanual hand performance (Both Hands Assessment), self-care and mobility (Pediatric Evaluation of Disability Inventory-Computer Adapted Test), goal attainment (Canadian Occupational Performance Measure), global performance of daily activities (ACTIVLIM-CP), cognition and adaptive function (Behavior Rating Inventory of Executive Function—Preschool Version), habitual physical activity (ActiGraph GT3X+) and quality of life (Infant Toddler Quality of Life Questionnaire and Child Health Utility Index-9). Analyses will follow standard principles for RCTs using two-group comparisons on all participants on an intention-to-treat basis. Comparisons between groups for primary and secondary outcomes will be conducted using regression models.Ethics and disseminationEthics approval has been granted by the Medical Research Ethics Committee Children’s Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC/19/QCHQ/59444) and The University of Queensland (2020000336/HREC/19/QCHQ/59444).Trial registration numberACTRN126200000719.

Objectives: The objective of this discussion paper is two-fold. The first is to quantify if the non-medical surgical assistant increases access to surgery by investigating what percentages of cases these clinicians undertake in the private sector surgical units where they work. The second is to examine procedural and distributive justice and how they impact on private sector surgical care. Aim: The aim of this paper is to investigate if the non-medical surgical assistant increases equity via access, for the patient, to private sector surgical care; and if government policy has an impact on equity in the form of access. Background: The private healthcare sector completes approximately two-thirds of all elective surgery in Australia; without this contribution, there would be more pressure on the public healthcare sector. In the private sector, recognition and federal funding of the surgical assistant differs depending on whether this clinician has a medical or non-medical, eg. nursing, qualification. The role of the non-medical surgical assistant is well established internationally and this role has been practiced in Australia for more than 20 years. Discussion: Inequity; as a result of the procedural injustice of government funding policy, impacts the private sector surgical patient causing distributive injustice. This distributive injustice results in an out-of-pocket expense to the patient. Rising outof-pocket expenses has started a trend of patients moving away from private health insurance and into the public sector. The registered nurse and nurse practitioner are qualified to practise as a non-medical surgical assistant and provide increased access to care, and effective care compared to the medical surgical assistant. The nurse practitioner is an eligible provider of Medical Benefits Schedule services but restricted from accessing the intraoperative assisting item numbers. Conclusion: The non-medical surgical assistant; or at least the nurse practitioner as non-medical surgical assistant; require access to the Medical Benefits Schedule intraoperative item numbers. Access would alleviate the out-of-pocket expense incurred by Australian patients when a non-medical surgical assistant assists with their surgery. Lack of access to these item numbers means patients may have their surgery delayed until an appropriately skilled medical surgical assistant is available, or the public healthcare sector can accommodate them. Implications for research, policy and practice: This paper illustrates a need for change in Australian government policy to reflect contemporary, evidencebased practice. What is already known about the topic? • The international literature reports that advanced practice nursing roles increase access to healthcare. • The nurse practitioner role in Australia is now well established, and the Australian literature illustrates increased access to care. • The Medical Benefits Schedule Review Taskforce was formed to investigate a system that is not consistent with contemporary, evidence-based healthcare. What this paper adds: • The nurse practitioner and registered nurse, in the role of non-medical surgical assistant, increase access to private sector surgical care. • Australian government policy limits access to private sector surgical care through its inequitable policies that contravene the spirit of fair trade. • According to peak professional bodies’ policy and position statements, the nurse practitioner and registered nurse are legitimate providers of surgical assisting services.

The aim of this study is to test what effect the weather may have on medications prescribed to treat Parkinson's disease. Twenty-three years of monthly time, series data was sourced from the Pharmaceutical Benefits Scheme (PBS) and the Bureau of Meteorology (BOM). Data were available for eight states and territories and their corresponding capital cities. The dependent variable was the aggregate levodopa equivalent dose (LED) for 51 Parkinson's medications identified on the PBS. Two explanatory variables of interest, temperature and solar exposure, were identified in the BOM data set. Linear and cosinor models were estimated with fixed and random effects, respectively. The prescribed LED was 4.2% greater in January and 4.5% lower in July. Statistical analysis showed that temperature was associated with the prescription of Parkinson medications. Our results suggest seasonality exists in Parkinson's disease symptoms and this may be related to temperature. Further work is needed to confirm these findings and understand the underlying mechanisms as a better understanding of the causes of any seasonal variation in Parkinson's disease may help clinicians and patients manage the disease more effectively.

Background Movement disorders (MDs) are increasingly being managed with deep brain stimulation (DBS). High‐quality economic evaluations (EEs) are necessary to evaluate the cost‐effectiveness of DBS. We conducted a systematic review of published EEs of the treatment of MDs with DBS. The review compares and contrasts the reported incremental cost‐effectiveness ratios (ICERs) and methodology employed by trial‐based evaluations (TBEs) and model‐based evaluations (MBEs). Methods MeSH and search terms relevant to “MDs,” “DBS,” and “EEs” were used to search biomedical and economics databases. Studies that used a comparative design to evaluate DBS, including before‐after studies, were included. Quality and reporting assessments were conducted independently by 2 authors. Seventeen studies that targeted Parkinson's disease (PD), dystonia, and essential tremor (ET), met our selection criteria. Results Mean scores for methodological and reporting quality were 73% and 76%, respectively. The ICERs for DBS compared with best medical therapy to treat PD patients obtained from MBEs had a lower mean and range compared with those obtained from TBEs ($55,461–$735,192 per quality‐adjusted life‐year [QALY] vs. $9,301–$65,111 per QALY). Pre‐post ICER for DBS to treat dystonia was $64,742 per QALY. DBS was not cost‐effective in treating ET compared with focused‐ultrasound surgery. Cost‐effectiveness outcomes were sensitive to assumptions in health utilities, surgical costs, battery life‐span, model time horizons, and the discount rate. Conclusions The infrequent use of randomized, controlled trials to evaluate DBS efficacy, the paucity of data reporting the long‐term effectiveness and/or utility of DBS, and the uncertainty surrounding cost data limit our ability to report cost‐effectiveness summaries that are robust.

Empirically separating the phenomena of moral hazard and adverse selection in insurance markets has occupied researchers in this field for decades. Recently, the potential benefits of using survey data instead of claims data to control for the different dimensions of private information when testing for evidence of asymmetric information have been explored in the insurance literature. This article extends that approach to present two tests for ex ante moral hazard in a market for automobile insurance. In this article we specify (1) a recursive model and (2) an instrumental variables model to address endogeneity with respect to policy selection in cross-sectional road traffic crash (RTC) survey data. We report a statistically significant ex ante moral hazard effect with both models. This result is then subjected to a falsification test, whereby the analysis is repeated in subsamples of at-fault and not-at-fault RTCs. Our antitest produces no evidence of ex ante moral hazard in the sub-sample of not-at-fault RTCs, in which the true moral hazard may reasonably be assumed to be zero, thus supporting the interpretation of the results of our two models. Our extension of the existing literature via these two specifications may have useful analogs in other insurance markets for which survey data are available.

Objectives:The composition of the medical costs incurred by people treated for basal cell and squamous cell carcinomas (hereafter keratinocyte cancers) is not adequately understood. We sought to compare the medical costs of individuals with or without keratinocyte cancers.Methods:We used national health insurance data to analyze the direct medical costs of 2000 cases and 2000 controls nested within the QSkin prospective cohort study (n = 43,794) conducted in Australia. We reconstructed the medical history of patients using medical and pharmaceutical item codes and then compared the health service costs of individuals treated for keratinocyte cancers with those not treated for keratinocyte cancers.Results:Individuals treated for keratinocyte cancers consumed on average AUD$1320 per annum more in medical services than those without keratinocyte cancers. Only 23.2% of costs were attributed to the explicit treatment of keratinocyte cancers. The principal drivers of the residual costs were medical attendances, surgical procedures on the skin, and histopathology services. We found significant positive associations between history of treatment for keratinocyte cancers with treatments for other health conditions, including melanoma, cardiovascular disease, lipidemia, osteoporosis, rheumatoid arthritis, colorectal cancer, prostate cancer, and tuberculosis.Conclusion:Individuals treated for keratinocyte cancers have substantially higher medical costs overall than individuals without keratinocyte cancers. The direct costs of skin cancer excision account for only one-fifth of this difference.

Our objective was to estimate the cost of inpatient malnutrition conditional upon admitting diagnosis and recorded nutritional treatment. We analysed an anonymised administrative data set for inpatients treated in hospitals in Victoria, Australia 2003-2004. The data set included patient-level cost, clinical markers, demographic and episode variables. The data set was analysed to identify codes, which indicated the presence of malnutrition or its treatment. Linear regression was used to ascertain to what extent malnutrition affected the cost of admission. Controlling for the underlying condition and any treatment administered, recorded malnutrition is estimated to add AU $1,745 per admission. The total cost of coded malnutrition to the Victorian public hospital system in 2003-2004 was estimated to be least AU $10.7 million. Only 1.87% of inpatients were coded as malnourished. As administrative data are known to underreport the prevalence of malnutrition, our estimate represents a credible lower boundary on the true cost of inpatient malnutrition.

The medical record is a repository of clinical data, which can greatly enhance the quality of health and healthcare analysis. Administrative data are collected for the purpose of billing and reimbursement, and are valued by health researchers because the data are routinely audited to maintain accurate financial records. However, the quantity of incorporated clinical data can be variable. In this paper we reconstruct the medical record from health service invoices to estimate the cost of treating keratinocytic cancer (KC). The data from an epidemiological survey were linked to an administrative data set supplied by the national health insurer. A matched sampling technique with multivariable analysis was used to estimate cost. A KC treatment was identified with 42 service codes which explicitly nominated treatment of a KC. Algorithms identifying comorbities potentially correlated with KC were constructed from the service codes. The annual cost of a KC treatment was estimated to be AU$667 per individual. The average cost of explicit KC treatments was AU$231, while the cost of generic procedures used to treat KC was AU$436. Our ability to accurately control for the medical history enabled our analysis to quantify and describe the constituent costs of KC treatment. Electronic supplementary material The online version of this article (doi:10.1186/s13561-015-0042-x) contains supplementary material, which is available to authorized users.

Objective To estimate the relative inpatient costs of hospital-acquired conditions. Methods Patient level costs were estimated using computerized costing systems that log individual utilization of inpatient services and apply sophisticated cost estimates from the hospital's general ledger. Occurrence of hospital-acquired conditions was identified using an Australian ‘condition-onset’ flag for diagnoses not present on admission. These were grouped to yield a comprehensive set of 144 categories of hospital-acquired conditions to summarize data coded with ICD-10. Standard linear regression techniques were used to identify the independent contribution of hospital-acquired conditions to costs, taking into account the case-mix of a sample of acute inpatients (n 5 1,699,997) treated in Australian public hospitals in Victoria (2005/ 06) and Queensland (2006/07). Results The most costly types of complications were post-procedure endocrine/metabolic disorders, adding AU$21,827 to the cost of an episode, followed by MRSA (AU$19,881) and enterocolitis due to Clostridium difficile (AU$19,743). Aggregate costs to the system, however, were highest for septicaemia (AU$41.4 million), complications of cardiac and vascular implants other than septicaemia (AU$28.7 million), acute lower respiratory infections, including influenza and pneumonia (AU$27.8 million) and UTI (AU$24.7 million). Hospital-acquired complications are estimated to add 17.3% to treatment costs in this sample. Conclusions Patient safety efforts frequently focus on dramatic but rare complications with very serious patient harm. Previous studies of the costs of adverse events have provided information on ‘indicators’ of safety problems rather than the full range of hospital-acquired conditions. Adding a cost dimension to priority-setting could result in changes to the focus of patient safety programmes and research. Financial information should be combined with information on patient outcomes to allow for cost-utility evaluation of future interventions.

The consequences of spinal cord injury are profound and extend well beyond the immediate loss ofmobility and sensation. Employment is a well-recognised rehabilitation goal. In this study, we examine the impact of a publicly funded "package" of services that is designed to enable people with a spinal cord injury to return to the workplace. Specifically, this package of services provided client directed assistance for assisting the recipient with the activities of daily living (e.g., bathing, food preparation, etc.).Wecombine primary data collection methods well developed in other scientific disciplines, but less frequently utilised within economics, with traditional econometric techniques, to present a novel approach to this methodological issue. The Spinal Injuries Survey Instrument was developed and administered using amatched sampling approach. Collected data included, labour market outcomes, exposure to the packages, as well as clinical and demographic covariates commonly identified by the spinal cord injury literature. Concern for endogeneity was addressed by collecting data on several variables that might serve as suitable instruments for the econometric work and measures of otherwise-unobserved sources of heterogeneity. For example, a psychological measure of "attributional style was adapted from the field of psychology in order to control for a potentially confounding source of latent individual heterogeneity, viz. " motivation". While our results find zero marginal effect of support packages on labour market outcomes, we find that training undertaken post-injury and age are both positively correlated with labour market participation. © 2010 Elsevier B.V. All rights reserved.

Introduction Patient safety efforts are often recommended solely on judgments about the relative importance of particular adverse events in hospital care, without considering the frequency and costs of all hospital-acquired illness and injury. The objective of the study was to use patient-level cost data to estimate relative economic priorities for hospital inpatient safety efforts. Methods Patient level costs are estimated using computerized patient costing systems that initially log individual utilization of inpatient services, and then apply sophisticated cost estimates from the hospital's general ledger. The occurrence of a hospital-acquired diagnosis is identified using a new Australian 'condition-onset' flag for all diagnoses not present on admission. These diagnoses are grouped to yield a comprehensive set of 144 categories of hospital-acquired conditions, using a recently-developed algorithm to summarize data coded with ICD-10-AM. Standard linear regression techniques are used to identify the independent contribution to inpatient costs of hospital- acquired conditions, taking into account the case mix of a sample of acute inpatients (n = 1,699,997) treated in Australian public hospitals in Victoria (2005/06) and Queensland (2006/07). Results The most costly types of adverse events were post-procedure endocrine and metabolic disorders, adding $A 21,869 to the cost of an episode, followed by (methicillinresistant staphylococcus aureus) MRSA (+$A 19,892) and enterocolitis due to Clostridium difficile (+$A 19,745). Aggregate additional costs to the system were highest for septicaemia (+$A 41.5 mil), complications of cardiac and vascular implants other than septicaemia (+$A 28.7 mil), acute lower respiratory infections -- including influenza and pneumonia ($A 28.0 mil) -- and UTI (+$A 24.7 mil). Hospital acquired complications are estimated to add 17.1% to the costs of treatment in this sample. Conclusion Patient safety efforts frequently focus on dramatic but rare complications with very serious patient harms. Adding an economic dimension to priority-setting could result in changes to the priorities of patient safety programs. It could also provide guidance as to other areas where research into causes and prevention strategies may prove a productive investment. Financial information should be combined with information on patient harms to allow for cost-utility evaluation of future programs.

The incidence and cost of complications occurring in older and younger inpatients were compared.Secondary analysis of hospital-recorded diagnosis and costs for multiday-stay inpatients in 68 public hospitals in two Australian states.A complication is defined as a hospital-acquired diagnosis that required additional treatment. The Australian Classification of Hospital-Acquired Diagnoses system is used to identify these complications.Inpatients aged70 years have a 10.9% complication rate, which is not substantially different from the 10.89% complication rate found in patients aged70 years. Examination of the probability by single years, however, showed that the peak incidence associated with the neonatal period and childbirth is balanced by rates of up to 20% in patients80 years. Examining the adult patient population (40-70 years), we found that while some common complications are not age specific (electrolyte disorders and cardiac arrhythmias), others (urinary tract and lower respiratory tract infections) are more common in the older adult inpatient.For inpatients aged70 years, the risks of complications increase. The incidence of hospital-acquired diagnoses in older adults differs significantly from incidence rates found in younger cohorts. Urinary tract infection and alteration to mental state are more common in older adult inpatients. Surprisingly, these complexities do not result in additional costs when compared with costs for the same complications in younger adults. Greater awareness of these differing patterns will allow patient safety efforts for older patients to focus on complications with the highest incidence and cost.