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Separating selection bias from moral hazard in private health insurance (PHI) markets has been a challenging task. We estimate selection bias and moral hazard in Australia's mixed public-private health system, where PHI premiums are community-rated rather than risk-rated. Using longitudinal cohort data, with fine-grained measures for medical services predominantly funded by PHI providers, we find consistent and robust estimates of advantageous selection among hospitalized cardiovascular disease (CVD) patients. Specifically, we show that in addition to their risk-averse attributes, CVD patients who purchase PHI use fewer services that are not covered by PHI providers (e.g., general practitioners and emergency departments) and have fewer comorbidities. Finally, unlike previous studies, we show that ex-post moral hazard exists in the use of specific "in-hospital" medical services such as specialist and physician services, miscellaneous diagnostic procedures, and therapeutic treatments. From the perspective of PHI providers, the annual cost of moral hazard translates to a lower bound estimate of $707 per patient, equivalent to a 3.03% reduction in their annual profits., (© 2022 The Authors. Health Economics published by John Wiley & Sons Ltd.)

Background: Cardiovascular disease (CVD) is one of the leading causes of death in Australia. Longitudinal record linkage studies have the potency to influence clinical decision making to improve cardiac health. This paper describes the baseline characteristics of the Queensland Cardiac Record Linkage Cohort study (QCard)., Methods: International Classification of Disease, 10th Revision Australian Modification (ICD-10-AM) diagnosis codes were used to identify CVD and comorbidities. Cost and adverse health outcomes (e.g., comorbidities, hospital-acquired complications) were compared between first-time and recurrent admissions. Descriptive statistics and standard tests were used to analyse the baseline data., Results: There were 132,343 patients with hospitalisations in 2010, of which 47% were recurrent admissions, and 53% were males. There were systematic differences between characteristics of recurrent and first-time hospitalisations. Patients with recurrent episodes were nine years older (70 vs. 61; p < 0.001) and experienced a twice higher risk of multiple comorbidities (3.17 vs. 1.59; p < 0.001). CVD index hospitalisations were concentrated in large metropolitan hospitals., Conclusions: Our study demonstrates that linked administrative health data provide an effective tool to investigate factors determining the progress of heart disease. Our main finding suggests that recurrent admissions were associated with higher hospital costs and a higher risk of having adverse outcomes., (© 2022. The Author(s).)

Objective: Cardiovascular disease (CVD) is the leading cause of hospitalisations and deaths in Australia. This study estimates the excess CVD hospitalisations and deaths across seasons and during the December holidays in Queensland, Australia. Methods: The study uses retrospective, longitudinal, population-based cohort data from Queensland, Australia from January 2010 to December 2015. The outcomes were hospitalisations and deaths categorised as CVD-related. CVD events were grouped according to when they occurred in the calendar year. Excess hospitalisations and deaths were estimated using the multivariate ordinary least squares method after adjusting for confounding effects. Results: More CVD hospitalisations and deaths occurred in winter than in summer, with 7811 (CI: 1353, 14,270; p < 0.01) excess hospitalisations and 774 (CI: 35, 1513; p < 0.01) deaths compared to summer. During the coldest month (July), there was an excess of 42 hospitalisations and 7 deaths per 1000 patients. Fewer CVD hospitalisations (-20 (CI: -29, -9; p < 0.01)) occurred during the December holidays than any other period during the calendar year. Non-CVD events were mostly not statistically significant different between periods. Conclusion: Most CVD events in Queensland occurred in winter rather than during the December holidays. Potentially cost-effective initiatives should be explored such as encouraging patients with CVD conditions to wear warmer clothes during cold temperatures and/or insulating the homes of CVD patients who cannot otherwise afford to.

Objectives: To estimate the incidence-based, lifetime costs of health care and productivity losses associated with cardiovascular disease (CVD) using hospital admission data from Queensland, Australia., Methods: Retrospective analysis of data on CVD health care use sourced from Queensland Hospital Admitted Patient Data Collection (QHAPDC), Emergency Department Data Collection (EDDC), Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS). Costs were estimated from the societal perspective. Study participants included patients who were first admitted to any Queensland hospital in 2010 for a CVD-related treatment. Subsequent admissions of these patients were followed until December 2015. The present value of incidence-based lifetime costs per patient were used to estimate the total costs for Australia. All costs were presented in Australian dollars at 2019 prices., Results: The estimated lifetime health care cost of CVD was AUD$65,700 per person. Productivity loss cost was higher at AUD$75,200 per person, and total indirect lifetime costs were $140,900 per person. Scaling these costs up for the Australian population, the estimated incidence-based lifetime CVD costs for Australia were $60.5 billion ($28.2 billion in direct costs and $32.3 billion in indirect costs)., Conclusions: Incidence-based lifetime indirect costs of CVD were higher than the direct costs. The life-time cost structure suggests that economic benefits of health care interventions for cardiovascular diseases from a societal perspective should be at least twice as large than that from a health service perspective., (Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Cardiovascular diseases (CVDs) remain a global health challenge due to number of deaths and use of healthcare services related to the condition. Although a plethora of studies have shown the impact of unemployment on health outcomes, evidence on the unemployment effects on the demand for expensive cardiac healthcare services is rare. This study exploits longitudinal cohort dataset to examine the impact of variations in local level unemployment rate on the demand for healthcare services among working aged people with CVD in Australia. Our findings show an inverse relationship between unemployment and the demand for healthcare services. Specifically, we find that a rising unemployment reduces the demand for primary and secondary healthcare services, with the largest effect observed for hospital admissions and hospitalisation days. We further show that rising unemployment at the local level has a greater impact on CVD patients with comorbidities and those who live in nonremote areas. Finally, our estimates suggest that increasing local level unemployment averts a substantial number of healthcare services use, leading to an unintended cost savings of $1.2 million to the health sector.

This study uses longitudinal cohort data to estimate the impacts of air pollution on health outcomes among people first hospitalised with heart diseases. Despite the generally low level of pollution in Australia, we find that acute exposure to pollution increases readmissions to hospitals within 3-12 months after discharge and is more evident among those suffering from heart failure. We further show that chronic exposure to air pollution increases the risk of death within 72 months, hospital admissions and general practitioner (GP) visits. Patients with coronary heart disease or cerebrovascular disease are the most affected groups. Finally, a cost saving of $1.3 billion will be generated to the health sector, if the monthly concentration of PM 10 and CO was lowered to 15.49 µg/m 3 and 122.99 µg/m 3 , respectively. The findings from our study emphasize the need for policies that target significant reduction in ambient PM 10 and CO to decrease the demand for scarce healthcare resources for cardiac diseases.

Background: The Coaching On Achieving Cardiovascular Health (COACH) Program has been proven to improve biomedical and lifestyle cardiovascular disease (CVD) risk factors. The objective of this study was to evaluate the long-term impact of The COACH Program on overall survival, hospital utilization, and costs from the perspective of a private health insurer (payor), in patients with CVD., Methods: A prospective parallel-group case-control study design with controls randomly matched to patients based on propensity score. There were 512 participants with CVD engaged in a structured disease management program of 6 months duration (The COACH Program) who were matched to 512 patients with CVD who were allocated to the control group. The independent variables that estimated the propensity score were preprogram hospital admissions, age, and sex. The primary outcome was overall survival with secondary outcomes, including hospital utilization and cost incurred by the private health insurer. Mean follow-up was 6.35 years. Difference in overall survival between the 2 groups was estimated using a Cox proportional hazard ratio (HR) with difference in total cost estimated using a generalized linear model., Results: The COACH Program achieved a significant reduction in overall mortality (HR 0.70; 95% confidence interval [CI], 0.53-0.93; P = .014). There was an apparent dose-response effect: those who received up to 3 coaching sessions had no decrease in mortality (HR 1.02; 95% CI, 0.69-1.49; P = .926); those who received 4 or more coaching sessions had a substantial decrease in mortality (HR 0.58; 95% CI, 0.42-0.81; P = .001). Total cost to the health insurer was substantially lower in the intervention group ($12,707 per person lower; P = .078). The reduction in total cost was significantly greater in those who received 4 or more sessions ($19,418 per person; P = .006) and in males ($18,947 per person; P = .029)., Conclusions: Those enrolled in The COACH program achieved a statistically significant decrease in overall mortality compared with usual care at 6.35 years. A substantive reduction in hospital costs was also observed among those who received The COACH program compared with those who did not, particularly in those who received 4 or more sessions and in males., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Multi-attribute utility instruments (MAUIs) are widely used to measure utility weights. This study sought to compare utility weights of two popular MAUIs, the EQ-5D-3L and the SF-6D, and inform researchers in the selection of generic MAUI for use with cardiovascular (CVD) patients., Methods: Data were collected in the Young@Heart study, a randomised controlled trial of a nurse-led multidisciplinary home-based intervention compared to standard usual care. Participants (n = 598) completed the EQ-5D-3L and the SF-12v2, from which the SF-6D can be constructed, at baseline and at 24-month follow-up. This study examined discrimination, responsiveness, correlation and differences across the two instruments., Results: Both MAUIs were able to discriminate between the NYHA severity classes and recorded similar changes between the two time points although only SF-6D differences were significant. Correlations between the dimensions of the two MAUIs were low. There were significant differences between the two instruments in mild conditions but they were similar in severe conditions. Substantial ceiling and floor effects were observed., Conclusions: Our findings indicate that the EQ-5D and the SF-6D cover different spaces in health due to their classification systems. Both measures were capable of discriminating between severity groups and responsive to quality of life changes in the follow-up. It is recommended to use the EQ-5D-3L in severe and the SF-6D in mild CVD conditions.

Background: The reported cost effectiveness of cardiovascular disease management programs (CVD-MPs) is highly variable, potentially leading to different funding decisions. This systematic review evaluates published modeled analyses to compare study methods and quality., Methods: Articles were included if an incremental cost-effectiveness ratio (ICER) or cost-utility ratio (ICUR) was reported, it is a multi-component intervention designed to manage or prevent a cardiovascular disease condition, and it addressed all domains specified in the American Heart Association Taxonomy for Disease Management. Nine articles (reporting 10 clinical outcomes) were included., Results: Eight cost-utility and two cost-effectiveness analyses targeted hypertension (n=4), coronary heart disease (n=2), coronary heart disease plus stoke (n=1), heart failure (n=2) and hyperlipidemia (n=1). Study perspectives included the healthcare system (n=5), societal and fund holders (n=1), a third party payer (n=3), or was not explicitly stated (n=1). All analyses were modeled based on interventions of one to two years' duration. Time horizon ranged from two years (n=1), 10 years (n=1) and lifetime (n=8). Model structures included Markov model (n=8), 'decision analytic models' (n=1), or was not explicitly stated (n=1). Considerable variation was observed in clinical and economic assumptions and reporting practices. Of all ICERs/ICURs reported, including those of subgroups (n=16), four were above a US$50,000 acceptability threshold, six were below and six were dominant., Conclusion: The majority of CVD-MPs was reported to have favorable economic outcomes, but 25% were at unacceptably high cost for the outcomes. Use of standardized reporting tools should increase transparency and inform what drives the cost-effectiveness of CVD-MPs., (© The European Society of Cardiology 2014.)

Substantial variation in economic analyses of cardiovascular disease management programs hinders not only the proper assessment of cost-effectiveness but also the identification of heterogeneity of interest such as patient characteristics. The authors discuss the impact of reporting and methodological variation on the cost-effectiveness of cardiovascular disease management programs by introducing issues that could lead to different policy or clinical decisions, followed by the challenges associated with net intervention effects and generalizability. The authors conclude with practical suggestions to mitigate the identified issues. Improved transparency through standardized reporting practice is the first step to advance beyond one-off experiments (limited applicability outside the study itself). Transparent reporting is a prerequisite for rigorous cost-effectiveness analyses that provide unambiguous implications for practice: what type of program works for whom and how.