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Objective The National Institute for Health and Care Excellence (NICE) updated its eligibility criteria for unilateral cochlear implants (UCIs) in 2019. NICE claimed this would not impact the cost-effectiveness results used within its 2009 technology appraisal guidance. This claim is uncertain given changed clinical practice and increased healthcare unit costs. Our objective was to estimate the cost-effectiveness estimates of UCIs in UK adults with severe to profound hearing loss within the contemporary NHS environment. Methods A cost–utility analysis employing a Markov model was undertaken to compare UCIs with hearing aids or no hearing aids for people with severe to profound hearing loss. A clinical pathway was developed to estimate resource use. Health-related quality of life, potential adverse events, device upgrades and device failure were captured. Unit costs were derived mostly from the NHS data. Probabilistic sensitivity analysis further assessed the effect of uncertain model inputs. Results A UCI is likely to be deemed cost-effective when compared to a hearing aid (£11,946/QALY) or no hearing aid (£10,499/QALY). A UCI has an 93.0% and 98.7% likelihood of being cost-effective within the UK adult population when compared to a hearing aid or no hearing aid, respectively. ICERs were mostly sensitive to the proportion of people eligible for cochlear implant, discount rate, surgery and device costs and processor upgrade cost. Conclusion UCIs remain cost-effective despite changes to clinical practice and increased healthcare unit costs. Updating the NICE criteria to provide better access UCIs is projected to increase annual implants in adults and children by 70% and expenditure by £28.6 million within three years. This increased access to UCIs will further improve quality of life of recipients and overall social welfare.

Objectives While all newborns in Australia are tested for congenital hearing loss through universal newborn hearing screening programs, some children will acquire hearing loss in their first five years of life. Delayed diagnosed or undiagnosed hearing loss in children can have substantial immediate- and long-term consequences. It can significantly reduce school readiness, language and communication development, social and emotional development, and mental health. It can also compromise lifetime educational achievements and employment opportunities and future economic contribution to society through lost productivity. The need for a universal hearing screening program for children entering their first year of primary school has been noted in two separate Australian Government hearing inquiries in the last decade. Sound Scouts is a hearing screening application (app) that tests for hearing loss in children using a tablet or mobile device, supervised by parents at home. It tests for sensorineural or permanent conductive hearing loss and central auditory processing disorder in children. In 2018 the Australian Government funded the roll-out of Sound Scouts to allow up to 600,000 children to test their hearing using Sound Scouts. This study estimated the cost-effectiveness of screening 5-year-old children for hearing loss using Sound Scouts at home, compared with no screening. Design A decision-analytic model was developed to estimate the incremental costs and quality-adjusted life years (QALYs) of administering Sound Scouts over a 20-year time horizon. Testing accuracy was based on comparing Sound Scouts test results to clinical test results while other parameters were based on published data. Costs were estimated from the perspective of the Australian health care system. Univariate and probabilistic sensitivity analyses were undertaken. Results Sound Scouts is estimated to result in an average incremental cost of A$61.02 and an average incremental increase in QALYs of 0.01. This resulted in an incremental cost-effectiveness ratio of A$5392 per QALY gained, which is likely to be considered cost-effective by Australian decision makers. Screening with Sound Scouts was found to have a 96.2 per cent probability of being cost-effective using a threshold of A$60,000 per QALY gained. Conclusions Using Sound Scouts to screen five-year-old children for hearing loss (at home) is likely to be cost-effective. Screening children using Sound Scouts will result in early identification and intervention in childhood hearing loss, thereby reducing early childhood disadvantage through cumulative gains in quality of life, education, and economic outcomes over their lifetime.

Health technology assessment has been increasingly used in China, having been legally mandated in 2019, to inform reimbursement decisions and price negotiations between the National Healthcare Security Administration and pharmaceutical companies around the price of new pharmaceuticals. The criteria currently used to judge cost effectiveness and inform pricing negotiations, 3 × GDP per capita, is based on the rule of thumb previously recommended by the World Health Organization rather than an estimate based on an empirical assessment of health opportunity costs. The objective of this study was to inform a cost-effectiveness threshold for health technology assessment in China that accounts for health opportunity cost. The elasticity of health outcomes with respect to health expenditure was estimated using variations across 30 provincial-level administrative divisions in 2017 controlling for a range of other factors and using an instrumental variable approach to account for endogeneity to assess robustness of results. The estimated elasticity was then used to calculate the cost per disability-adjusted life-year (DALY) averted by variations in Chinese health expenditure at the margin. The range estimated from this study, 27,923–52,247 (2017 RMB) (central estimate 37,446) per DALY averted or 47–88% of GDP per capita (central estimate 63%), shows that a cost per DALY averted cost-effectiveness threshold that reflects health opportunity costs is below 1 × GDP per capita. Our results suggest that the current cost-effectiveness threshold used in China is too high; continuing to use it risks decisions that reduce overall population health.

Objective The 686 project provides free essential drugs and follow-up for poor SMD patients, with the purpose of improving patients' medication adherence and reducing the occurrence of dangerous behaviors. The objective of this research was to determine the factors that influence medication adherence in patients with severe mental disorders (SMD) and analyze whether the 686 program significantly improved patient medication adherence. Methods This study was conducted among SMD patients in 686 project and non-project SMD patients in the same community in 11 cities in Shandong Province of China. The data collected included basic patient information and disease treatment information. Medication adherence was divided into good adherence and poor adherence. Propensity score matching (1:1 match) was performed to adjust for differences in baseline characteristics. Results One thousand two hundred ninety-two patients receiving free medication assistance policy (686 project group) and 1292 non-policy patients (control group) were analyzed. Patients who received the 686 project group had significantly better medication adherence than the non-policy group patients (92.6% vs.61.2%). Older age and consolidation period were associated with poor adherence, and education level was the positive determinant for adherence. Conclusion The 686 project could improve medication adherence to patients with SMD. Additional research will pay attention to medication adherence of patients who are elderly, in consolidation period and lower education levels. It should strengthen the guidance and supervision of patients' medication and strengthen the health education of family members and patients.

Objective To construct a whole-of-system model to inform strategies that reduce the burden of cardiovascular disease (CVD) in Australia. Methods A system dynamics model was developed with a multidisciplinary modelling consortium. The model population comprised Australians aged 40 years and over, and the scope encompassed acute and chronic CVD as well as primary and secondary prevention. Health outcomes were CVD-related deaths and hospitalisations, and economic outcomes were the net benefit from both the healthcare system and societal perspectives. The eight strategies broadly included creating social and physical environments supportive of a healthy lifestyle, increasing the use of preventive treatments, and improving systems response to acute CVD events. The effects of strategies were estimated as relative differences to the business-as-usual between 2019–2039. Probabilistic sensitivity analysis produced uncertainty intervals of interquartile ranges (IQR). Findings The greatest reduction in CVD-related deaths was seen in strategies that improve systems response to acute CVD events (8.9%, IQR: 7.7–10.2%), yet they resulted in an increase in CVD-related hospitalisations due to future recurrent admissions (1.6%, IQR: 0.1–2.3%). This flow-on effect highlighted the importance of addressing underlying CVD risks. On the other hand, strategies targeting the broad environment that supports a healthy lifestyle were effective in reducing both hospitalisations (7.1%; IQR: 5.0–9.5%) and deaths (8.1% reduction; IQR: 7.1–8.9%). They also produced an economic net benefit of AU$43.3 billion (IQR: 37.7–48.7) using a societal perspective, largely driven by productivity gains. Overall, strategic planning to reduce the burden of CVD should consider the varying effects of strategies over time and beyond the health sector.

Background Group-based trajectory modelling (GBTM) has recently been explored internationally as an improved approach to measuring medication adherence (MA) by differentiating between alternative temporal patterns of nonadherence. To build on this international research, we use the method to identify temporal patterns of medication adherence to antidepressants, bisphosphonates or statins, and their associations with patient characteristics. Objectives The objectives include identification of MA types using GBTM, exploration of features and associated patient characteristics of each MA type, and identification of the advantages of GBTM compared to the traditional proportion of days covered (PDC) measure. Data and methods We used 45 and Up Study survey data which contains information about demographics, family, health, diet, work and lifestyle of 267,153 participants aged at least 45 years across New South Wales, Australia. This data was linked to participant records of medication use, outpatient and inpatient care, and death. Our study participants initiated use of antidepressants (9287 participants), bisphosphonates (1660 participants) or statins (10,242 participants) during 2012–2016. MA types were identified from 180-day patterns of medication use for antidepressants and 360-day patterns for bisphosphonates and statins. Multinomial and binomial logistic regressions were performed to estimate participant characteristics associated with GBTM MA and PDC MA, respectively. Results Three GBTM MA types were identified for antidepressants and six for bisphosphonates and statins. For all three medications, MA types included: almost fully adherent; decreasing adherence and early discontinuation. The additional nonadherent types for bisphosphonates and statins were improved adherence, low adherence and later discontinuation. Participant characteristics impacting GBTM MA and PDC MA were consistent. However, several associations were uniquely found for GBTM MA as compared to PDC MA. Conclusion GBTM permits clinicians, policy-makers and researchers to differentiate between alternative nonadherence patterns, allowing them to better identify patients at risk of poor adherence and tailor interventions accordingly., Highlights • Medication adherence was categorised using group-based trajectory modelling (GBTM). • GBTM categories include adherence, early discontinuation and decreasing adherence. • Demographic, economic, health and other factors determined GBTM categories. • GBTM provides additional information to better target adherence interventions.

© 2019 ISPOR–The Professional Society for Health Economics and Outcomes Research Background: Migraine is a common, chronic, disabling headache disorder. Triptans, used as an acute treatment for migraine, are available via prescription in Australia. An Australian Therapeutic Goods Administration (TGA) committee rejected reclassifying sumatriptan and zolmitriptan from prescription medicine to pharmacist-only between 2005 and 2009, largely on the basis of concerns about patient risk. Nevertheless, pharmacist-only triptans may reduce migraine duration and free up healthcare resources. Objectives: To estimate the cost-effectiveness of reclassifying triptans from prescription-only to pharmacist-only in Australia. Methods: The study design included decision-analytic modeling combining data from various sources. Behavior before and after reclassification was estimated using medical practitioner and patient surveys and also administrative data. Health outcomes included migraine frequency and duration as well as adverse events (AEs) discussed by the TGA committee. Efficacy and AEs were estimated using randomized controlled trials and observational studies. Results: Reclassifying triptans will reduce migraine duration but increase AEs. This will result in 337 quality-adjusted life-years gained at an increased cost of A$5.9 million over 10 years for all Australian adults older than 15 years (19.6 million). The incremental cost-effectiveness ratio was estimated to be A$17 412/quality-adjusted life-year gained. Conclusions: The incremental cost-effectiveness ratio is likely to be considered cost-effective by Australian decision makers. Serotonin syndrome, a key concern of the TGA committee, had little impact on the results. Further research is needed regarding pharmacist-only triptan use by migraineurs currently using over-the-counter medicines and by nonmigraineurs, the efficacy of triptans, and the risk of cardiovascular and cerebrovascular AEs and chronic headaches with triptans.

Background Research has shown unilateral cochlear implants (CIs) significantly improve clinical outcomes and quality of life in adults. However, only 13% of eligible Swedish adults currently use a unilateral CI. The objective was to estimate the cost-effectiveness of unilateral CIs compared to a hearing aid for Swedish adults with severe to profound hearing loss. Methods A Markov model with a lifetime horizon and six-month cycle length was developed to estimate the benefits and costs of unilateral CIs from the Swedish health system perspective. A treatment pathway was developed through consultation with clinical experts to estimate resource use and costs. Unit costs were derived from the Swedish National Board of Health and Welfare and the Swedish Association of Local Authorities and Regions. Health outcomes were reported in terms of Quality Adjusted Life Years (QALYs). Results Unilateral CIs for Swedish adults with severe to profound hearing loss are likely to be deemed cost-effective when compared to a hearing aid (SEK 140,474 per QALY gained). The results were most sensitive to the age when patients are implanted with a CI and the proportion of patients eligible for CIs after triage. Conclusions An increase in the prevalence of Swedish adults with severe to profound hearing loss is expected as the population ages. Earlier implantation of unilateral CIs improves the cost-effectiveness among people eligible for CIs. Unilateral CIs are an efficacious and cost-effective option to improve hearing and quality of life in Swedish adults with severe to profound hearing loss.

Background In 2017, the NSW Central Coast Local Hospital District (CCLHD) designed and implemented the Outcomes Based Care program to vulnerable older people healthy and at home. Two not for profit providers were commissioned to deliver their own form of care coordination for one year. Provider payments were based on their capacity to reduce unplanned public hospital bed days for an allocated patient cohort. Objectives Our study objectives were to explore how provider and service characteristics, along with patient behaviours, and mediators and moderators of service delivery, may have impacted outcomes. These included hospital utilisation, health outcomes and patient experience with care coordination. Methods The process evaluation explored mechanisms of impact and contextual factors, including the risk stratification approach, frailty of the patient cohort and impact of the funding incentives for care coordination between the CCLHD, community providers and hospitals. Evaluation criteria were developed after a systematic literature review. Information was collected through patient surveys, interviews with patients, providers, the CCLHD and additional program documentation. Results The primary outcomes showed a significant reduction in hospital activity for both the intervention and the control group. While there was an overall decrease in hospital use, modelling results suggest Outcomes Based Care increased ED visits for the intervention group. The risk stratification approach resulted in the selection of a cohort of older patients with more complex patients than anticipated. The funding incentives shifted financial risk to providers, but all allocated unplanned hospital bed days were used within six months with the contract needing to be renegotiated. Survey data suggests providers supported patients in the self-management of their medical conditions but is unclear whether the level of patient engagement was appropriate to achieve intended outcomes. Providers note the lack of General Practitioner and patient engagement hampered efforts to improve health outcomes. Discussion International experience presents similar results for care coordination approaches. A review of 15 randomised trials developed within the US found only three coordinated care programs experienced a significant difference in hospitalisations. One program increased hospitalisations by 19 per cent. Similar findings were identified in the UK with significantly increased ED visits and unplanned hospitalisations compared to control groups, though these weren’t part of a commissioning pilot. Limitations Survey data was intended to be collected at enrolment and again when Outcomes Based Care finished. They were not administered as planned and the timings varied for each survey and between the enrolled and control groups. Response rates also varied by survey type and mode of administration. One provider, in particular did not capture adequate evaluation data. Conclusions The study has important evidence based implications for the development of approaches designed to keep older people healthy and at home and to incentivise the delivery of care. Lessons learned Fourteen evaluation recommendations explore health outcomes, cost effectiveness, patient experience and unintended consequences that specifically relate to outcomes based commissioning designed to keep older people healthy and at home. Suggestions for future research Further models of outcomes based funding should be piloted within the NSW healthcare system.

Background With expected increases in the number of older adults worldwide, the delivery of stepped psychological care for depression and anxiety in older populations may improve both treatment and allocative efficiency for individual patients and the health system. Design A multisite pragmatic randomised controlled trial evaluating the clinical and cost-effectiveness of a stepped care model of care for treating depression and anxiety among older adults compared to treatment as usual (TAU) will be conducted. Eligible participants (n = 666) with clinically interfering anxiety and/or depression symptoms will be recruited from and treated within six Australian mental health services. The intervention group will complete a low intensity cognitive behavioural therapy (CBT) program: Internet-delivered or using a work-at-home book with brief therapist calls (STEP 1). Following STEP 1 a higher intensity face-to-face CBT (STEP 2) will then be offered if needed. Intention-to-treat analyses will be used to examine changes in primary outcomes (e.g. clinician-rated symptom severity changes) and secondary outcomes (e.g. self-reported symptoms severity, health related quality of life and service utilisation costs). An economic evaluation will be conducted using a cost-utility analysis to derive the incremental cost-effectiveness ratio for the stepped care intervention. Discussion This study will demonstrate the relative clinical and economic benefits of stepped care model of psychological care for older adults experiencing anxiety and/or depression compared to TAU. The evaluation of the intervention within existing mental health services means that results will have significant implications for the translation of evidence-based interventions in older adult services across urban and rural settings. Trail registration Prospectively registered on anzctr.org.au (ACTRN12619000219189) and isrctn.com (ISRCTN37503850).

IntroductionFor individuals presenting to the emergency department (ED) for a suicide attempt, the period after discharge from hospital is marked by heightened vulnerability for further suicide attempts. Effective care following a suicidal crisis has the potential to significantly decrease this risk. The current study aims to examine the impact of the LifeSpan multilevel suicide prevention model on experiences of care following a suicidal crisis. Perspectives from healthcare consumers (individuals who have presented to the ED following a suicidal crisis), carers, and health professionals will be explored. The LifeSpan model is currently being evaluated as a high-fidelity trial in four geographically defined regions in New South Wales, Australia.Methods and analysisThis study will use a mixed methods prospective cohort design. Quantitative data collection includes a structured survey, administered to healthcare consumers from LifeSpan sites and control sites. Two cohorts of healthcare consumers will be recruited 12 months apart with baseline assessment occurring within 18 months of the ED presentation, and follow-up 12 months after the initial assessment. Survey participants will be recruited online and through participating EDs, mental health organisations and aftercare services. Qualitative interview data from healthcare consumers, carers who have accompanied a loved one to the ED following a suicidal crisis and health professionals who provide care to people at risk of suicide will be collected concurrently with the recruitment of the first cohort of survey participants. Purposive and convenience sampling techniques will be used for recruitment of interview participants. The primary outcome for this study will be healthcare consumers’ experiences of service provided at the ED. Analysis will be undertaken of the change over time within LifeSpan sites, as well as between LifeSpan sites and control sites, using mixed effects repeated measures models as principal means of data analysis.Ethics and disseminationThis research has been approved by the Hunter New England Human Research Ethics Committee (HREC/17/HNE/144). Results will be disseminated via conferences and peer-reviewed journals.Trial registration numberACTRN12617000457347.

Background Despite increasing investment in suicide prevention, Australian suicide rates have increased steadily in the past decade. In response to growing evidence for multicomponent intervention models for reducing suicide, the LifeSpan model has been developed as the first multicomponent, evidence-based, system-wide approach to suicide prevention in Australia. The LifeSpan model consists of nine evidence-based strategies. These include indicated, selective and universal interventions which are delivered simultaneously to community and healthcare systems over a 2-year implementation period. This study will evaluate the effectiveness of the LifeSpan model in reducing suicide attempts and suicide deaths in four geographically defined regions in New South Wales, Australia. Methods We outline the protocol for a stepped-wedge, cluster randomized controlled trial. Following a 6-month transition phase, the trial sites will move to the 2-year active implementation phase in 4-monthly intervals with evaluation extending a minimum of 24 months after establishment of the full active period. Analysis will be undertaken of the change attributable to the invention across the four sites. The primary outcome for the study is the rate of attempted suicide in the regions involved. Rate of suicide deaths within each site is a secondary outcome. Discussion If proven effective, the LifeSpan model for suicide prevention could be more widely delivered in Australian communities, providing a valuable new approach to tackle rising suicide rates. LifeSpan has the potential to significantly contribute to the mental health of Australians by improving help-seeking for suicide, facilitating early detection, and improving aftercare to reduce re-attempts. The findings from this research should also contribute to the evidence base for multilevel suicide prevention programs internationally. Trial registration Australia New Zealand Clinical Trials Register, ID: ACTRN12617000457347. Prospectively registered on 28 March 2017. https://www.anzctr.org.au/TrialSearch.aspx#&&conditionCode=&dateOfRegistrationFrom=&interventionDescription=&interventionCodeOperator=OR&primarySponsorType=&gender=&distance=&postcode=&pageSize=20&ageGroup=&recruitmentCountryOperator=OR Protocol Version: 1.0, 31 May 2019.

IntroductionValue-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond ‘what works’ towards more nuanced understanding of ‘what tends to work for whom under which circumstances’. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts.Methods and analysisThis exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context–mechanism–outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed.Ethics and disseminationEthical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.

Unplanned pregnancies can lead to poorer maternal and child health outcomes. The Australian Therapeutic Goods Administration committee rejected reclassifying a range of oral contraceptive pills (OCPs) from prescription to pharmacist-only medicines in 2015, mainly based on safety concerns. Improving access to OCPs may encourage some women to use contraceptives or switch from other contraceptive methods. However, some adverse events may increase and some women may stop using condoms, increasing their risk of sexually transmitted infections. This study aimed to estimate the cost effectiveness of reclassifying OCPs from prescription to pharmacist-only. Healthcare system. Australian primary care. A Markov model was used to synthesise data from a variety of sources. The model included all Australian women aged 15–49 years (N = 5,644,701). The time horizon was 35 years. Contraceptive use before reclassification was estimated using data from the Household, Income and Labour Dynamics in Australia (HILDA) survey, while survey data informed use after reclassification. Health outcomes included pregnancies, pregnancy outcomes (live birth, miscarriage, stillbirth, ectopic pregnancy and abortion), sexually transmitted infections, adverse events (venous thromboembolism, depression, myocardial infarction and stroke), ovarian cancer cases and quality-adjusted life-years. Costs included those related to general practitioner and specialist consultations, contraceptives and other medicines, pharmacist time, hospitalisations and adverse events. All costs were reported in 2016 Australian Dollars. A 5% discount rate was applied to health outcomes and costs. Reclassifying OCPs resulted in 85.70 million quality-adjusted life-years experienced and costs of $46,910.14 million over 35 years, vs. 85.68 million quality-adjusted life-years experienced and costs of $50,274.95 million with OCPs remaining prescription-only. Thus, reclassifying OCPs was more effective and cost saving. However, a sensitivity analysis found that more research on the probability of pregnancy in women not using contraception and not trying to conceive is needed. Reclassifying OCPs is likely to be considered cost effective by Australian decision makers.

Background The Central Coast Local Health District (CCLHD) implemented the Outcomes Based Commissioning pilot program in 2017 to keep older people with chronic conditions healthy and at home. CCLHD commissioned two not-for-profit organisations to provide care coordination services to an allocated cohort of patients over one year. Payment to providers was based on saved unplanned hospital bed days. Objectives Our study objective was to determine the impact of the CCLHD commissioning process on hospital use, health outcomes, and patient experience of care coordination. We also sought to develop recommendations to improve outcomes based commissioning approaches to keep people healthy and at home within the NSW healthcare system. Methods We developed a commissioning assessment framework by reviewing best practice commissioning approaches for healthcare, and the NSW Government’s commissioning policies and guidelines. We collected information on the CCLHD commissioning process from provider contracts and interviews held with providers and CCLHD. We used the assessment framework to compare CCLHD’s commissioning approach to best practice. Results CCLHD’s commissioning approach was aligned to the NSW Government’s commissioning policies and guidelines. A strong relationship developed between CCLHD and providers helped manage risk, supported by a robust monitoring framework. However, privacy requirements limited providers from using patient data to adequately assess their funding risk before being contracted. Limited access to timely unplanned public hospital data and discharge summaries reduced the ability of providers to manage their ongoing financial risk. Not all funding risk could be transferred to providers by CCLHD due to community obligations. The payment model did not adequately incentivise other desirable activities sought by CCLHD such as GP engagement. Conclusions The Outcomes Based Commissioning program was an innovative but complex approach to funding care coordination. There was little precedent within the NSW healthcare system from which CCLHD could draw upon. CCLHD involved providers in co-designing their commissioning approach. Discussion Providers were incentivised to reduce unplanned hospital bed days. Outcomes Based Commissioning also sought to increase health outcomes and patient and carer satisfaction with the health care system. While providers were asked to collect information on health outcomes through the PROMIS 10 survey, they were not directly incentivised to improve health outcomes nor increase patient and carer satisfaction. This meant there was some potential disconnect between service outcomes desired by CCLHD and provider intentions. Lessons learned Create incentives for providers to undertake other desired behaviours through payment linked to key performance objectives. This could include secondary analysis of process measures alongside primary outcome measures. Limitations Our commissioning results are limited to a 12-month pilot study conducted in one setting involving two providers. In addition, the Outcomes Based Commissioning program was designed to address local needs and conditions and some findings are context specific. These aspects limit transferability of the results. Suggestions for future research Additional evaluation studies are needed on outcomes based commissioning approaches in order to develop greater guidance for policy makers on the powers and pitfalls of using commissioning approaches and outcomes based funding models to achieve integrated care aims.

Objective The Da Qing Diabetes Prevention program (DQDP) was a randomized lifestyle modification intervention conducted in 1986 for the prevention and control of type 2 diabetes in individuals with impaired glucose tolerance. The current study estimated long-term cost-effectiveness of the program based on the health utilities from the Chinese population. Methods A Markov Monte Carlo model was developed to estimate the impact of the intervention from the healthcare system perspective. The analysis was run over 30-year and lifetime periods and costs were estimated respectively as health management service costs. Baseline characteristics and intervention effects were assessed from the DQDP. Utilities and costs were generated from relevant literature. The outcome measures were program cost per quality-adjusted life-years (QALYs) gained and incremental cost-effectiveness ratio (ICER) of the intervention. Sensitivity analyses and threshold analyses were performed. Results Using a 30-year horizon, the intervention strategy was cost-saving and was associated with better health outcomes (increase of 0.74 QALYs per intervention participant). Using a lifetime horizon, the intervention strategy was cost-saving and was associated with additional 1.44 QALYs. Sensitivity analyses showed that the overall ICER was most strongly influenced by the hazard ratio of cardiovascular disease event. Conclusions The Da Qing lifestyle intervention in a Chinese population with impaired glucose tolerance is likely to translate into substantial economic value. It is cost-saving over a 30-year time and lifetime frame.

Most Chinese patients tend to seek primary care services in tertiary hospitals rather than community clinics, which has caused the malfunction of China's multi-tiered health system. This study aimed to identify the factors that affected patients' decisions when selecting healthcare facilities and use these to design policies to redirect patient flow from tertiary hospitals back to community clinics. A cross-sectional survey was conducted in Shanghai in 2017 using the best-worst scaling experiment. A total of 202 respondents were included in the analysis, including 97 community residents, 56 tertiary hospital patients, and 49 community clinic patients. The latter two had made their choices so the three samples were analyzed separately. Seven attributes were used in the experiment with each varying across two or three levels to accommodate the features of primary care services in Shanghai. The values of attribute levels were estimated using the mixed logit model. Relative importance across attributes and attribute levels were derived and policy simulations were undertaken to examine the impact of changing attribute levels on choices. Results suggest that the three samples are composed of different types of people who presented different preference patterns. The community residents are representative of the population and to them sufficient test and examinations, doctors with expertise, and good service attitude are the most desirable features for a healthcare facility while unfriendly practitioners and lengthy visit the least attractive features. In terms of attributes, friendliness of doctors and the availability of tests and examinations are the two major drivers in selecting healthcare facilities. Our findings provide supportive evidence and useful inputs to the ongoing healthcare reform in China.

Introduction: The North East Wyong region consists primarily of an aged population with the lowest socioeconomic status on the Central Coast in Australia. There is a high rate of hospital admissions in aged patients with chronic diseases, and this fragmented, complex and costly healthcare behooves alternative care to better manage this patient group in a community or sub-acute setting. In 2017, Central Coast will implement an outcomes based care program. It represents the first payment structure based upon the delivery of outcomes rather than activity for integrated care in Australia. Aim: We have developed a research protocol to evaluate the process and cost-effectiveness of implementing the outcomes based payment model, and to explore the potential unintended consequences from non-government provision of coordinated care. Target population and stakeholders: The overall objective is to provide coordinated access to cost effective care to vulnerable patients aged 65 years and above with two or more chronic conditions who are at risk of unplanned hospitalisation. The programme will commence in January 2017 for one year. The design is a non-randomised intervention study. The intervention and control group of patients were identified as being ‘at risk’ of hospital admission through a risk stratification algorithm used by Central Coast Local Health District (CCLHD). The algorithm is based on age, disease and previous hospital admissions. Two private providers will provide social care services to the population. The intervention group will be attached to two general practices per provider. A control group of matched patients will allow comparisons between the integrated care programme and usual care. Providers are incentivised to improve patient health with payment managed through a shared risk arrangement with CCLHD. Part of the reimbursement to providers will be calculated based on the total number of saved unplanned public hospital inpatient days. Methods: The overall design is a mixed-methods study using primarily quantitative and additional qualitative data from general practices and service providers, patient reported outcomes, patient and carer interviews, and interviews and focus group data from staff in general practices and service providers. A process evaluation will examine whether the program was implemented as planned, stakeholder response to the programme, characteristics of enrolled and drop-out patients, accuracy of the risk stratification algorithm in predicting unplanned public hospital inpatient days, impact of the program and any changes in service delivery during the study. An economic evaluation to be undertaken from a societal perspective, will provide the financial cost of the outcomes based care model according to utilisation of services and cost per patient according to clinical condition, and the rate of avoidable hospitalisations. Costs to the patient, CCLHD, federal government and the private sector (providers, NGOs and GPs) are included, where the data allows. Transferability: This evaluation will generate a better understanding of the factors that can influence the implementation, feasibility and sustainability of adapting outcomes based care to fit other healthcare and social contexts within Australia and internationally. It will also highlight the usefulness of a purpose built algorithm to estimate unplanned public hospital inpatient bed days.

This study aims to provide a rigorous estimate of the worldwide costs of visual impairment (VI), and the associated health burden. The study used a prevalence-based model. Prevalence rates for mild VI (visual acuity (VA) worse than 6/12 but not worse than 6/18), moderate VI (VA worse than 6/18 but not worse than 6/60) and blindness (VA worse than 6/60) were applied to population forecasts for each World Health Organisation (WHO) subregion. The limited available country cost data were extrapolated between subregions using economic and population health indicators. Age and gender subgroup population numbers were derived from United Nations' data. Costs and the health burden of VI were estimated for each world subregion using published disease prevalence rates, health care expenditures and other economic data. The study includes direct health care costs, indirect costs and the health burden of VI. The total cost of VI globally was estimated at $3 trillion in 2010, of which $2.3 trillion was direct health costs. This burden is projected to increase by approximately 20% by 2020. VI is associated with a considerable disease burden. Unless steps are taken to reduce prevalence through prevention and treatment, this burden will increase alongside global population growth.

The object of this NATO Advanced Study Institute was to pre- sent a tutorial 'introduction both to the basic physics of recent spectacular advances achieved in the field of metrology and to the determination of fundamental physical constants. When humans began to qualify their description of natural phenomena, metrology, the science of measurement, developed along- side geometry and mathematics. However, flam antiquity to modern times, the role of metrology was mostly restricted to the need of commercial, social or scientific transactions of local or at most national scope. Beginning with the Renaissance, and particularly in western Europe during the last century, metrology rapidly developed an international character as a result of growing needs for more accurate measurements and common standards in the emerging indus- trial society. Although the concerns of metrology are deeply rooted to fundamental sciences, it was, until recently, perceived by much of the scientific community as mostly custodial in character.