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Background Statistical analysis plans describe the processes of data handling and analysis in clinical trials; by doing so they increase the transparency of the analysis and reporting of studies. This paper reports the planned statistical analysis plan for the Whiplash ImPaCT study. For individuals with whiplash injury, Whiplash ImPaCT aims to assess the effectiveness of a guidelines-based clinical pathway of care compared with usual care. Methods We report the planned procedures, methods, and reporting for the primary and secondary analyses of the Whiplash ImPaCT study. The primary outcomes are Global Recovery and Neck Disability Index at 3 months post-randomisation. Outcomes will be analysed according to the intention to treat principle using linear mixed models. A cost-utility analysis will be conducted to compute the incremental cost-effectiveness of the intervention to usual care. We describe data handling, our analytical approach, assumptions about missing data, and our planned methods of reporting. Discussion This paper will provide a detailed description of the planned analyses for the Whiplash ImPaCT trial.

ObjectiveTo explore factors behind inpatient admissions by high-cost users (HCUs) in pre-end-stage chronic kidney disease (CKD).DesignRetrospective analysis of CKD.QLD Registry and hospital admissions of the Queensland Government Department of Health recorded between 1 July 2011 and 30 June 2016.SettingQueensland public and private hospitals.Participants5096 individuals with CKD who consented to the CKD.QLD Registry via 1 of 11 participating sites.Main outcomesAssociations of HCU status with patient characteristics, pathways and diagnoses behind hospital admissions at 12 months.ResultsAge, advanced CKD, primary renal diagnosis, cardiovascular disease and hypertension were predictors of the high-cost outcome. HCUs were more likely than non-HCUs to be admitted by means of episode change (relative risk: 5.21; 95% CI 5.02 to 5.39), 30-day readmission (2.19; 2.13 to 2.25), scheduled readmission (1.29; 1.11 to 1.46) and emergency (1.07; 1.02 to 1.13), for diagnoses of the nervous (1.94; 1.74 to 2.15), circulatory (1.24; 1.14 to 1.34) and respiratory (1.2; 1.03 to 1.37) systems and other factors influencing health status (1.92; 1.74 to 2.09).ConclusionsThe high relevance of episode change and other factors influencing health status revealed that a substantial part of excess demand for inpatient care was associated with discordant conditions often linked to frailty, decline in psychological health and social vulnerability. This suggests that multidisciplinary models of care that aim to manage discordant comorbidities and address psychosocial determinants of health, such as renal supportive care, may play an important role in reducing inpatient admissions in this population.

Kidney supportive care (KSC) is a patient-centered model of multidisciplinary care designed for patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD). Our goal was to characterize the types, frequencies, and costs of services accessed by patients enrolled in a KSC program. We analyzed health care utilization data prospectively collected from 102 patients who enrolled in the KSC program during the first 52 weeks of its existence. The data comprised program appointments, emergency department presentations, ambulance service use, outpatient visits, inpatient episodes, and dialysis treatments made within the Brisbane area of Metro North. Costs of resource use were estimated using Queensland Health funding principles and guidelines. Analyses included descriptive statistics, correlations, and multivariate regressions. During the median program participation of 22 weeks, patients had 3975 contacts with health care, with the total value of services amounting to nearly A$3 million. Dialysis treatments accounted for 70% of visits and 49% of costs. Patients receiving dialysis had higher utilization of outpatient services and associated cost, compared to patients who were not dialyzed. The presence of diabetes and the choice of conservative pathway were both predictors of higher frequency and cost of services. Longer program participation was associated with lower weekly utilization and cost. The program attracted patients representing various characteristics, pathways, needs, and outcomes. Exploring these patterns will enable better understanding of the patient population and improved service planning, in KSC and similar programs that aim to comprehensively address the needs of patients with advanced CKD and ESKD.

Over the past few decades, integrated care (IC) has been emphasised as solution that promises to make the supply of health care more effective and efficient and for managing consumers’ demands for services. Yet, as decades of empirical evidence now demonstrate, the more Panglossian predictions of IC’s promise have been frustrated. Indeed, the weight of evidence from papers in the peer-reviewed literature—across all relevant disciplines—demonstrate that IC interventions often have modest effects on their intended targets. We argue that a range of structural factors, that are not typically emphasised by non-economists who write on this topic, are the key to understanding how and why particular IC interventions tend to fail (or succeed). We emphasise the unique perspective and comparative advantage that economists can bring to bear on this topic by incorporating the role of systemic and institutional structures and the incentives that are inherent in them, as central to analyses of what types of IC are (un)likely to work. In particular, some of the structural elements of extant health systems are more of the nature of constraints than fungible instruments of health policy. Our objective is to develop an economic characterisation of the microeconomic problems of different types of IC initiatives and their implementation, followed by a taxonomy of them that pertains directly to commonly-observed differences in health system characteristics (which we label “macroeconomic” factors). We argue that interventions in the set referred to generically as “IC”, are quite heterogenous and that between countries, and sometimes even within them, health systems are also characterised by considerable heterogeneity. Taking the latter as more-or-less exogenous, we seek to illustrate how these microeconomic and macroeconomic characteristics combine to make particular kinds of IC interventions more successful and more likely to be effective and sustainable in some health care systems than in others.

Recent economic literature has advanced the notion that cognitive biases and behavioural barriers may be important influencers of uptake decisions in respect of public programs that are designed to help disadvantaged people. This paper provides the first evidence on the determinants of uptake of two recent public dental benefit programs for Australian children and adolescents from disadvantaged families. Using longitudinal data from a nationally representative survey linked to administrative data with accurate information on eligibility and uptake, we find that only a third of all eligible families actually claim their benefits. These actual uptake rates are about half of the targeted access rates that were announced for them. We provide new and robust evidence consistent with the idea that cognitive biases and behavioural factors are barriers to uptake. For instance, mothers with worse mental health or riskier lifestyles are much less likely to claim the available benefits for their children. These barriers to uptake are particularly large in magnitude: together they reduce the uptake rate by up to 10 percentage points (or 36%). We also find some indicative evidence about the presence of the lack of information barrier to uptake. The results are robust to a wide range of sensitivity checks, including controlling for possible endogenous sample selection.

Objective: To investigate whether integrating pharmacists into general practices reduces the number of unplanned re-admissions of patients recently discharged from hospital. Design, setting: Stepped wedge, cluster randomised trial in 14 general practices in southeast Queensland. Participants: Adults discharged from one of seven study hospitals during the seven days preceding recruitment (22 May 2017 ‒ 14 March 2018) and prescribed five or more long term medicines, or having a primary discharge diagnosis of congestive heart failure or exacerbation of chronic obstructive pulmonary disease. Intervention: Comprehensive face-to-face medicine management consultation with an integrated practice pharmacist within seven days of discharge, followed by a consultation with their general practitioner and further pharmacist consultations as needed. Major outcomes: Rates of unplanned, all-cause hospital re-admissions and emergency department (ED) presentations 12 months after hospital discharge; incremental net difference in overall costs. Results: By 12 months, there had been 282 re-admissions among 177 control patients (incidence rate [IR], 1.65 per person-year) and 136 among 129 intervention patients (IR, 1.09 per person-year; fully adjusted IR ratio [IRR], 0.79; 95% CI, 0.52‒1.18). ED presentation incidence (fully adjusted IRR, 0.46; 95% CI, 0.22‒0.94) and combined re-admission and ED presentation incidence (fully adjusted IRR, 0.69; 95% CI, 0.48‒0.99) were significantly lower for intervention patients. The estimated incremental net cost benefit of the intervention was $5072 per patient, with a benefit‒cost ratio of 31:1. Conclusion: A collaborative pharmacist‒GP model of post-hospital discharge medicines management can reduce the incidence of hospital re-admissions and ED presentations, achieving substantial cost savings to the health system. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12616001627448 (prospective).

There has been a rapid increase in the use of behavioural economics (BE) as a tool for policy makers to deploy, including in health-related applications. While this development has occurred over the past decade, health care systems have continued to struggle with escalating costs. We consider the potential role of BE for making improvements to health care system performance and the sustainability of publicly funded health care systems, in particular. We argue that the vast majority of applications in this field have been largely focussed on BE and public health, or the prevailing level of risks to health in populations, and with policy proposals to 'nudge' individual behaviour (e.g. in respect of dietary choices). Yet, improvements in population health may have little, if any, impact on the size, cost or efficiency of health care systems. Few applications of BE have focussed on the management, production, delivery or utilisation of health care services per se. The latter is our focus in this paper. We review the contributions on BE and health care and consider the potential for complementing the considerable work on BE and public health with a clear agenda for behavioural health care economics. This agenda should complement the work of conventional microeconomics in the health care sector.

Deep-brain stimulation (DBS) can be effective in controlling medically intractable symptoms of Tourette’s syndrome (TS). There is no evidence to date, though, of the potential cost-effectiveness of DBS for this indication. To provide the first estimates of the likely cost-effectiveness of DBS in the treatment of severe TS. We conducted a cost-utility analysis using clinical data from 17 Australian patients receiving DBS. Direct medical costs for DBS using non-rechargeable and rechargeable batteries and for the alternative best medical treatment (BMT), and health utilities for BMT were sourced from the literature. Incremental cost-effectiveness ratios (ICERs) were estimated using a Markov models with a 10-year time horizon and 5% discount rate. DBS increased quality-adjusted life year (QALY) gained from 2.76 to 4.60 over a 10-year time horizon. The ICER for DBS with non-rechargeable (rechargeable) batteries, compared to BMT, was A$33,838 (A$15,859) per QALY. The ICER estimates are sensitive to DBS costs and selected time horizon. Our study indicates that DBS may be a cost-effective treatment for severe TS, based on the very limited clinical data available and under particular assumptions. While the limited availability of data presents a challenge, we also conduct sensitivity analyses to test the robustness of the results to the assumptions used in the analysis. We nevertheless recommend the implementation of randomised controlled trials that collect a comprehensive range of costs and the use of a widely accepted health-related quality of life instrument to enable more definitive statements about the cost-effectiveness of DBS for TS.

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.