Search

Objective The study sought to review the different assessment items that have been used within existing health app evaluation frameworks aimed at individual, clinician, or organizational users, and to analyze the scoring and evaluation methods used in these frameworks. Materials and Methods We searched multiple bibliographic databases and conducted backward searches of reference lists, using search terms that were synonyms of “health apps,” “evaluation,” and “frameworks.” The review covered publications from 2011 to April 2020. Studies on health app evaluation frameworks and studies that elaborated on the scaling and scoring mechanisms applied in such frameworks were included. Results Ten common domains were identified across general health app evaluation frameworks. A list of 430 assessment criteria was compiled across 97 identified studies. The most frequently used scaling mechanism was a 5-point Likert scale. Most studies have adopted summary statistics to generate the total scoring of each app, and the most popular approach taken was the calculation of mean or average scores. Other frameworks did not use any scaling or scoring mechanism and adopted criteria-based, pictorial, or descriptive approaches, or “threshold” filter. Discussion There is wide variance in the approaches to evaluating health apps within published frameworks, and this variance leads to ongoing uncertainty in how to evaluate health apps. Conclusions A new evaluation framework is needed that can integrate the full range of evaluative criteria within one structure, and provide summative guidance on health app rating, to support individual app users, clinicians, and health organizations in choosing or recommending the best health app.

Environmentalists have long warned of a coming shock to the system. COVID-19 exposed fragility in the system and has the potential to result in radical social change. With socioeconomic interruptions cascading through tightly intertwined economic, social, environmental, and political systems, many are not working to find the opportunities for change. Prefigurative politics in communities have demonstrated rapid and successful responses to the pandemic. These successes, and others throughout history, demonstrate that prefigurative politics are important for response to crisis. Given the failure of mainstream environmentalism, we use systemic transformation literature to suggest novel strategies to strengthen cooperative prefigurative politics. In this paper, we look at ways in which COVID-19 shock is leveraged in local and global economic contexts. We also explore how the pandemic has exposed paradoxes of global connectivity and interdependence. While responses shed light on potential lessons for ecological sustainability governance, COVID-19 has also demonstrated the importance of local resilience strategies. We use local manufacturing as an example of a possible localized, yet globally connected, resilience strategy and explore some preliminary data that highlight possible tradeoffs of economic contraction.

As understanding grows of the scale of health care's environmental impacts, so too does interest in measuring and reporting on sustainability as a facet of health care system performance. This article examines important lessons from health care's long experience with performance and quality measurement and reporting that can be applied to the creation of health care sustainability metrics. Although some large health systems such as Kaiser Permanente have invested heavily in environmental stewardship, in the US the focus of health care sustainability measurement and reporting has typically been on corporate social responsibility and climate risk disclosure. The ability of health care organizations to generate data on and control environmental impacts can be limited by legacy infrastructure and complex supply chains. However, just as in other domains of performance, health care sustainability measurement and reporting must proceed from a clear conceptual framework and statement of purpose. Measurement must reflect strategic goals, instead of letting goals become dictated by ease of measurement. Health system leaders now need to set clear and compelling sustainability goals, invest in internationally comparable metrics by which to measure their success, and embed them in their core business.

Background Within the Australian public hospital setting, no studies have previously reported total hospital utilisation and costs (pre/postoperatively) and costed patient-level pathways for primary bariatric surgery and surgical sequelae (including secondary surgery) informed by Australia’s Independent Hospital Pricing Authority’s activity-based funding (ABF) model. Objective We aimed to provide our Tasmanian state government partner with information regarding key evidence gaps about the resource use and costs of bariatric surgery (including pre- and postoperatively, types of surgery and comorbidities), the costs of surgical sequelae and policy direction regarding the types of bariatric surgery offered within the Tasmanian public hospital system. Methods Hospital inpatient length of stay (days), episodes of care (number) and aggregated cost data were extracted for people who were waiting for and subsequently received bariatric surgery (for the fiscal years 2007–2008 to 2015–2016) from administrative sources routinely collected, clinically coded/costed according to ABF. Aggregated ABF costs were expressed in 2016–2017 Australian dollars ($A). Sensitivity (cost outliers) and subgroup analyses were conducted. Results A total of 105 patients entered the study. Total costs (pre/postoperative over 8 years) for all inpatient episodes of care (n = 779 episodes of care) were $A6,018,349. When the ten cost outliers were omitted from the total cost, this cost reduced to $A4,749,265. Mean costs for primary laparoscopic adjustable gastric band (LAGB) and sleeve gastrectomy (SG) bariatric surgery were $A14,622 and $A15,014, respectively. The average cost/episode of care for people with diabetes decreased in the first year postoperatively, from $A7258 to $A5830/episode of care. In total, 27 LAGB patients (30%) required surgery due to surgical sequelae (including revisional/secondary surgery; n = 58 episodes of care) and 56% of these episodes of care were secondary LAGB device related (mostly port/reservoir related), with a mean cost of $A6267. Conclusions Taking into account our small SG sample size and the short time horizon for investigating surgical sequalae for SG, costs may be mitigated in the Tasmanian public hospital system by substituting LAGB with SG when clinically appropriate due to costs associated with the LAGB device for some patients. At 3 years postoperatively versus preoperatively, episodes of care and costs reduced substantially, particularly for people with diabetes/cardiovascular disease. We recommend that a larger confirmatory study of bariatric surgery including LAGB and SG be undertaken of disaggregated ABF costs in the Tasmanian public hospital system.

Background Demand for bariatric surgery in the public hospital setting in Australia is high with prolonged wait-list times. Policy-makers need to consider the consequences of expanding public bariatric surgery including on emergency department (ED) presentations. Aims To describe and evaluate public ED presentation rates and reasons for presenting in a cohort of patients wait-listed for public surgery. Methods All Tasmanians placed on the public wait-list for primary bariatric surgery in 2008–2013 were identified using administrative datasets along with their ED presentations in 2000–2014. The presentations were assigned to one of three periods: before wait-list placement, whilst on the wait-list, and after wait-list removal for publicly-funded surgery or drop-out. A negative binomial mixed-effects regression model was used to derive ED presentation incidence rate ratios (IRR) to compare observation periods and patient groups. Results 652 wait-listed patients had 5149 public ED presentations. 178 patients had publicly-funded bariatric surgery — all as laparoscopically adjustable gastric banding (LAGB). Overall, ED presentation rates did not change significantly post-surgery compared with the waiting period (IRR 1.19, 95%CI 0.90–1.56). Presentation rates significantly increased for digestive system (IRR 2.02, 95%CI 1.19–3.45) and psychiatric diseases (IRR 4.85, 95%CI 1.06–22.26) after surgery. The likelihood of being admitted from the ED significantly increased after surgery (31.7%–38.9%, p Conclusion ED presentations were common for patients wait-listed for public bariatric surgery and rates did not decrease over an average of three years post-LAGB. The likelihood of being admitted to the hospital from the ED increased after surgery.

Martin Hensher and Katharine Zywert examine some of the difficult changes that healthcare systems will need to make in the Anthropocene epoch

Background Choice of a multi-attribute utility instrument (MAUI) that appropriately assesses an intervention’s health-related quality-of-life (HRQoL) impacts is a vital part of healthcare resource allocation and clinical assessment. Objective Our exploratory study compared the EuroQol (EQ)-5D-5L and Assessment of Quality of Life (AQoL)-8D MAUIs, which were used to assess the effect of bariatric surgery for a cohort of long-term publicly waitlisted, severely obese patients. Methods The study was conducted at the Hobart Private Hospital (Tasmania, Australia). To compare the sensitivity and instrument content of the two MAUIs, we used dimensional comparisons by investigating the distribution of patient-reported responses (number/percentage) across the MAUIs’ levels and dimensions; summary health-state utility valuations (utilities); and individual/super-dimension scores (AQoL-8D) to investigate discriminatory power and HRQoL improvements preoperatively and 3 months postoperatively. Results Participants’ (n = 23) overall MAUI completion rate was 74%. Postoperative total weight loss was 9.9%. EQ-5D-5L utilities were relatively higher pre- and postoperatively than AQoL-8D utilities [mean standard deviation (SD) EQ-5D-5L 0.70 (0.25) to 0.80 (0.25); AQoL-8D 0.51 (0.24) to 0.61 (0.24)]. AQoL-8D Psychosocial super dimension was relatively low postoperatively [0.37 (0.25)], driving the instrument’s lower utility. These results were supported by the dimensional comparisons that revealed an overall greater dispersion for the AQoL-8D. Nevertheless, there were clinical improvements in utilities for both instruments. AQoL-8D utilities were lower than population norms; not so the EQ-5D-5L utilities. The AQoL-8D dimensions of Happiness, Coping, and Self-worth improved the most. Conclusions AQoL-8D more fully captured the impact of obesity and bariatric surgery on HRQoL (particularly psychosocial impacts) for long-term waitlisted bariatric surgery patients, even 3 months postoperatively. AQoL-8D preoperative utility revealed our population’s HRQoL was lower than people with cancer or heart disease. Electronic supplementary material The online version of this article (doi:10.1007/s41669-017-0060-1) contains supplementary material, which is available to authorized users.

Background Long-term publicly waitlisted bariatric surgery patients typically experience debilitating physical/psychosocial obesity-related comorbidities that profoundly affect their quality of life. Objectives We sought to measure quality-of-life impacts in a study population of severely obese patients who had multiyear waitlist times and then underwent bariatric surgery. Methods Participants were recruited opportunistically following a government-funded initiative to provide bariatric surgery to morbidly obese long-term waitlisted patients. Participants self-completed the EQ-5D-5L and AQoL-8D questionnaires pre- and postoperatively. Utility valuations (utilities) and individual/super dimension scores (AQoL-8D only) were generated. Results Participants’ (n = 23) waitlisted time was mean [standard deviation (SD)] 6.5 (2) years, body mass index reduced from 49.3 (9.35) kg/m2 preoperatively to 40.8 (7.01) 1 year postoperatively (p = 0.02). One year utilities revealed clinical improvements (both instruments). AQoL-8D improved significantly from baseline to 1 year, with the change twice that of the EQ-5D-5L [EQ-5D-5L: mean (SD) 0.70 (0.25) to 0.78 (0.25); AQoL-8D: 0.51 (0.24) to 0.67 (0.23), p = 0.04], despite the AQoL-8D’s narrower algorithmic range. EQ-5D-5L utility plateaued from 3 months to 1 year. AQoL-8D 1-year utility improvements were driven by Happiness/Coping/Self-worth (p

COVID-19 has shone a bright light on a number of failings and weaknesses in how current economic models handle information and knowledge Some of these are familiar issues that have long been understood but not acted upon effectively – for example, the danger that current systems of intellectual property and patent protection are actually inimical to delivering a cost-effective vaccine available to all, whereas treating knowledge as a commons and a public good is much more likely to deliver efficient outcomes for the entire global population But COVID-19 has also demonstrated that traditional models of knowledge production and dissemination are failing us;scientific knowledge is becoming weaponized and hyper-partisan, and confidence in this knowledge is falling We believe that the challenges that COVID-19 has exposed in the information economy and ecology will be of increasing applicability across the whole spectrum of sustainability;sustainability scholars and policymakers need to understand and grasp them now if we are to avoid contagion into other sectors due to the preventable errors that have marred the global response to COVID-19 Alternate abstract:Social media summaryCOVID-19 highlights both the failures of privatized knowledge and worrying fractures in the wider information ecology

The strong and positive relationship between gross domestic product (GDP) and health expenditure is one of the most extensively explored topics in health economics. Since the global financial crisis, a variety of theories attempting to explain the slow recovery of the global economy have predicted that future economic growth will be slower than in the past. Others have increasingly questioned whether GDP growth is desirable or sustainable in the long term as evidence grows of humanity's impact on the natural environment. This paper reviews recent data on trends in global GDP growth and health expenditure. It examines a range of theories and scenarios concerning future global GDP growth prospects. It then considers the potential implications for health care systems and health financing policy of these different scenarios. In all cases, a core question concerns whether growth in GDP and/or growth in health expenditure in fact increases human health and well-being. Health care systems in low growth or ‘post-growth’ futures will need to be much more tightly focused on reducing overtreatment and low value care, reducing environmental impact, and on improving technical and allocative efficiency. This will require much more concerted policy and regulatory action to reduce industry rent-seeking behaviours.

The objective of this study was to investigate the experience of waiting for publicly funded bariatric surgery in an Australian tertiary healthcare setting. Focus groups and individual interviews involving people waiting for or who had undergone publicly funded bariatric surgery were audio-recorded, transcribed and analysed thematically. A total of 11 women and 6 men engaged in one of six focus groups in 2014, and an additional 10 women and 9 men were interviewed in 2015. Mean age was 53 years (range 23-66); mean waiting time was 6 years (range 0-12), and mean time since surgery was 4 years (range 0-11). Waiting was commonly reported as emotionally challenging (e.g. frustrating, depressing, stressful) and often associated with weight gain (despite weight-loss attempts) and deteriorating physical health (e.g. development of new or worsening obesity-related comorbidity or decline in mobility) or psychological health (e.g. development of or worsening depression). Peer support, health and mental health counselling, integrated care and better communication about waitlist position and management (e.g. patient prioritization) were identified support needs. Even if wait times cannot be reduced, better peer and health professional supports, together with better communication from health departments, may improve the experience or outcomes of waiting and confer quality-of-life gains irrespective of weight loss.

Objective: To examine Australian patients’ motivations for seeking bariatric surgery. Background: The reasons for seeking bariatric surgery are incompletely understood. This information is needed to inform health-service planning and therapeutic decisions. Methods: Ten focus groups were audio-recorded, transcribed verbatim, and analyzed thematically. Results: Thirty-two women and 17 men (mean age 55 years; range 23–72) who had received or were waitlisted for publicly- or privately funded bariatric surgery engaged in the study. Novel findings highlighted the importance of other bariatric surgery recipients, health professionals’ recommendations (e.g., bariatric surgeons, medical specialists, and general practitioners), the media (e.g., televisions shows on bariatric surgery), and having private health insurance. We also confirmed previous findings that people seek surgery for physiological and psychological health, and because of previous failed weight loss attempts and significant others (e.g., wanting to...

Concerns have grown in recent decades that economic growth in many rich countries may, in fact, be uneconomic. Uneconomic growth occurs when expansion in economic activity causes environmental and social costs that are greater than the benefits of that additional activity. Health care has enjoyed a close historical relationship with economic growth, with health care spending consistently growing faster than GDP over the long term. This paper explores the possible relationship between health care and uneconomic growth. It summarises the rapidly growing evidence on the harms caused by poor quality health care and by the overuse of health care, and on the environmental harms caused by health care systems. Further, it develops a conceptual framework for considering the overconsumption of health care and the joint harms to human health and the natural environment that ensue. This framework illustrates how health-damaging overconsumption in the wider economy combines with unnecessary or low-quality health care to create a cycle of "failure demand" and defensive expenditure on health care services. Health care therefore provides important sectoral insights on the phenomenon of uneconomic growth. There are rich opportunities for interdisciplinary research to quantify the joint harms of overconsumption in health and health care, and to estimate the optimal scale of the health sector from novel perspectives that prioritise human and planetary health and well-being over GDP and profit.

As covid-19 drives unemployment rates around the world to levels unseen in generations, once radical economic policy proposals are rapidly gaining a hearing. Martin Hensher examines how job guarantee or universal basic income schemes might support better health and better economics

Objective To explore the support needs and experiences of patients who had received publicly or privately funded bariatric surgery and the importance of this support in mediating outcomes of surgery. Methods Seven semi-structured focus groups were conducted. A broad interview schedule guided the discussions which were audio-recorded and transcribed verbatim. Data were analysed thematically. Results Twenty-six women and 15 men with a mean age of 54 years (range 24–72) participated in the study. Participants described support needs from health professionals, significant others (family and friends), peers (bariatric surgery recipients) and the general community. Peer, dietetic and psychological support were identified as important factors influencing the outcomes (e.g. weight reduction or health improvement) or experience of bariatric surgery but were identified as infrequently received or inadequately provided. Psychological support was proposed as one of the most significant but commonly overlooked components of care. Support needs appeared higher in the first year post-surgery, when subsequent related or unrelated surgeries were required and following significant life change such as worsening health. For some participants, deficits in support appeared to negatively influence the experience or outcomes of surgery. Conclusion Providers of bariatric surgery should discuss support needs and accessibility regularly with patients especially in the first year post-surgery and following significant change in a patient's life (e.g. declined health or childbirth). Nutrition, psychological and peer support (e.g. through support groups) may be especially important for some patients.

The objective of the study was to determine the level of guidance provided by or to government health departments across different regions of Australia on publicly funded bariatric surgery. Bariatric surgery policies and guidelines were sought from each Australian state (n = 6) and territory (n = 2) government health department and compared in relation to their origins, level of guidance on patient eligibility and priority, as well as recommendations for patient care, including follow-up surgical services. Comparison with national guidelines on bariatric surgery from Australia, the UK and USA was also made. Five of the eight states and territories had policies or guidelines informing practice. There was little uniformity among regional guidelines and variable consistency with national guidelines (e.g., defining obesity related comorbidity). Recommendations differed on patient eligibility, and none of the state documents mentioned re-operative bariatric or body-contouring surgery. There was limited guidance on prioritisation of eligible patients and gastric banding adjustments. Pre- and post-surgical multidisciplinary care was generally recommended. Policies and guidelines on publicly funded bariatric surgery are highly variable across Australia and at times inconsistent with national guidelines. Insufficient guidance exists regarding the prioritisation of eligible patients and follow-up surgical services. These findings have implications for policy, research and practice and are particularly important in health service environments with resource constraints and inequitable patient access to services.

Objective The aim of the present study was to determine the potential demand for publicly and privately funded bariatric surgery in Australia. Methods Nationally representative data from the 2011–13 Australian Health Survey were used to estimate the numbers and characteristics of Australians meeting specific eligibility criteria as recommended in National Health and Medical Research Council guidelines for the management of overweight and obesity. Results Of the 3 352 037 adult Australians (aged 18–65 years) estimated to be obese in 2011–13, 882 441 (26.3%; 95% confidence interval (CI) 23.0–29.6) were potentially eligible for bariatric surgery (accounting for 6.2% (95% CI 5.4–7.1) of the adult population aged 18–65 years (n = 14 122 020)). Of these, 396 856 (45.0%; 95% CI 40.4–49.5) had Class 3 obesity (body mass index (BMI) ≥40 kg m–2), 470945 (53.4%; 95% CI 49.0–57.7) had Class 2 obesity (BMI 35–39.9 kg m–2) with obesity-related comorbidities or risk factors and 14 640 (1.7%; 95% CI 0.6–2.7) had Class 1 obesity (BMI 30–34.9 kg m–2) with poorly controlled type 2 diabetes and increased cardiovascular risk; 458 869 (52.0%; 95% CI 46.4–57.6) were female, 404 594 (45.8%; 95% CI 37.3–54.4) had no private health insurance and 309 983 (35.1%; 95% CI 28.8–41.4) resided outside a major city. Conclusion Even if only 5% of Australian adults estimated to be eligible for bariatric surgery sought this intervention, the demand, particularly in the public health system and outside major cities, would far outstrip current capacity. Better guidance on patient prioritisation and greater resourcing of public surgery are needed. What is known about this topic? In the period 2011–13, 4 million Australian adults were estimated to be obese, with obesity disproportionately more prevalent in areas of socioeconomic disadvantage. Bariatric surgery is considered to be cost-effective and the most effective treatment for adults with obesity, but is mainly privately funded in Australia (>90%), with 16 650 primary privately funded procedures performed in 2015. The extent to which the supply of bariatric surgery is falling short of demand in Australia is unknown. What does this paper add? The present study provides important information for health service planners. For the first time, population estimates and characteristics of those potentially eligible for bariatric surgery in Australia have been described based on the best available evidence, using categories that best approximate the national recommended eligibility criteria. What are the implications for practitioners? Even if only 5% of those estimated to be potentially eligible for bariatric surgery in Australia sought a surgical pathway (44 122 of 882 441), the potential demand, particularly in the public health system and outside major cities, would still far outstrip current capacity, underscoring the immediate need for better guidance on patient prioritisation. The findings of the present study provide a strong signal that more funding of public surgery and other effective interventions to assist this population group are necessary.

Increasing attention has been paid in recent years to the problem of "too much medicine", whereby patients receive unnecessary investigations and treatments providing them with little or no benefit, but which expose them to risks of harm. Despite this phenomenon potentially constituting an inefficient use of health care resources, it has received limited direct attention from health economists. This paper considers "too much medicine" as a form of overconsumption, drawing on research from health economics, behavioural economics and ecological economics to identify possible explanations for and drivers of overconsumption. We define overconsumption of health care as a situation in which individuals consume in a way that undermines their own well-being. Extensive health economics research since the 1960s has provided clear evidence that physicians do not act as perfect agents for patients, and there are perverse incentives for them to provide unnecessary services under various circumstances. There is strong evidence of the existence of supplier-induced demand, and of the impact of various forms of financial incentives on clinical practice. The behavioural economics evidence provides rich insights on why clinical practice may depart from an "evidence-based" approach. Moreover, behavioural findings on health professionals' strategies for dealing with uncertainty, and for avoiding potential regret, provide powerful explanations of why overuse and overtreatment may frequently appear to be the "rational" choice in clinical decision-making, even when they cause harm. The ecological economics literature suggests that status or positional competition can, via the principal-agent relationship in health care, provide a further force driving overconsumption. This novel synthesis of economic perspectives suggests important scope for interdisciplinary collaboration; signals potentially important issues for health technology assessment and health technology management policies; and suggests that cultural change might be required to achieve significant shifts in clinical behaviour.

Five recent economic evaluations comparing hospital at home schemes with acute hospital care faced remarkably similar problems. This paper outlines these problems and considers what strategies can be derived from these experiences, which will be relevant to economic evaluations of other aspects of the organisation of care, particularly those crossing the interfaces between primary and secondary health care or the interface between health and social services. The difficulties experienced can be divided into conceptual and practical problems. Conceptual problems were primarily associated with issues of context and related to the choice of comparator, capacity constraints and size of schemes, and the choice between a short or a long run perspective. Practical problems were connected with the time at which schemes were evaluated, the type of clinical study alongside which studies were conducted and the types of data available for use in the analysis. Strategies which can be pursued in conducting economic evaluations of organisational change include giving greater attention to conceptual and hence contextual problems as well as reporting these contextual issues in detail, accepting the need for repeated economic evaluations as organisational changes become more widespread and considering carefully the clinical study design where economic evaluations of organisational change are conducted alongside. These strategies are of importance not just to those conducting economic evaluations but also to those funding appraisals of changes in the organisation of care. Use of different strategies such as those suggested here should be evaluated.

Objectives: Health needs assessment gained prominence under the model of health care purchasing developed to support the 1991 reforms of the UK National Health Service (NHS). The objectives of this paper are to determine how needs assessment has been used in the NHS, to assess the influence it has had on decision-making, and to relate the observed uses of needs assessment to competing theoretical models of health care policy-making. Methods: A survey of needs assessment activity in 14 London health authorities identified 217 needs assessments conducted between 1993 and 1996. Semi-structured interviews were conducted with public health and commissioning staff in each authority. Results: The survey indicated that needs assessment directly supported decision-making and action in two-thirds of the studies identified, but up to 20% of needs assessments had no impact on service provision. Four key functions of health needs assessment were observed: identifying a problem; planning detailed changes to services; providing post hoc justification for earlier decisions; and using participation in needs assessment to build ‘ownership’ of subsequent decisions. Conclusions: The survey suggests that needs assessment is, in practice, consistent with a ‘mixed scanning’ model of decision-making. Needs assessment is used to help select issues for detailed investigation and to direct analytical and decision-making resources. However, certain key areas are not amenable to technical analysis and solution, and are resolved through bargaining.