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Background Medication Assisted Treatment for Opioid Dependence (MATOD) is clinically effective and cost effective, yet a lack of MATOD prescribers in the community limits access to this treatment in Australia. These shortages are often greatest in regional and rural areas. Objective(s) The Enhancing Pharmacists Involvement in Care (EPIC)-MATOD study will evaluate clinical and implementation outcomes among people with opioid dependence receiving MATOD through a collaborative pharmacist-prescriber model of care across multiple sites in a regional location (encompassing a mix of metropolitan and non-metropolitan areas) of Victoria, Australia. Methods and analysis The EPIC-MATOD study is a prospective, multisite, implementation trial of collaborative MATOD care. Pharmacists and prescribers will be recruited through the local network of opioid pharmacotherapy providers. Patients will be recruited through participating healthcare providers. After induction into the collaborative care model, patients and healthcare professionals will be followed up over 6- (patients) and 12-months (pharmacists and prescribers) in a hybrid implementation-efficacy study, with outcomes mapped to the RE-AIM framework. The primary clinical efficacy endpoint is patient retention in treatment at 26 weeks. The primary implementation outcome is treatment capacity, based on prescriber time required to provide treatment through collaborative care compared with traditional care. Secondary clinical endpoints include attendance for dosing and clinical reviews, substance use, mental and physical health and overall well-being. Implementation costs, acceptability, and provider engagement in collaborative care will be used as secondary implementation outcome indicators. Time and costs associated with collaborative care, and health service utilisation, will also be estimated. Project impact The study will provide important information on outcomes and acceptability of collaborative care for MATOD, as well as the cost and key considerations in delivering a collaborative model of care in Australia and other countries where similar treatment barriers exist.

Objectives To the best of our knowledge, no published clinical guidelines have ever undergone an economic evaluation to determine whether their implementation represented an efficient allocation of resources. Here, we perform an economic evaluation of national clinical guidelines designed to reduce unnecessary blood transfusions before, during, and after surgery published in 2012 by Australia’s sole public blood provider, the National Blood Authority (NBA). Methods We performed a cost analysis from the government perspective, comparing the NBA’s cost of implementing their perioperative patient blood management guidelines with the estimated resource savings in the years after publication. The impact on blood products, patient outcomes, and medication use were estimated for cardiac surgeries only using a large national registry. We adopted conservative counterfactual positions over a base-case 3-year time horizon with outcomes predicted from an interrupted time-series model controlling for differences in patient characteristics and hospitals. Results The estimated indexed cost of implementing the guidelines of A$1.5 million (2018-2019 financial year prices) was outweighed by the predicted blood products resource saving alone of A$5.1 million (95% confidence interval A$1.4 million-A$8.8 million) including savings of A$2.4 million, A$1.6 million, and A$1.2 million from reduced red blood cell, platelet, and fresh frozen plasma use, respectively. Estimated differences in patient outcomes were highly uncertain and estimated differences in medication were financially insignificant. Conclusions Insofar as they led to a reduction in red blood cell, platelet, and fresh frozen plasma use during cardiac surgery, implementing the perioperative patient blood management guidelines represented an efficient use of the NBA’s resources.

‘Altruism born of suffering’ (ABS) predicts that, following an adverse life event such as a health shock, individuals may become motivated to help others and act pro-socially. However, despite anecdotal support this has not been examined systematically. Using data from the United States Panel Study of Income Dynamics, we find that an adverse health shock does not lead to a general increase in pro-social behaviour; it neither causes people to start giving, nor does it spark an increase in donations across charitable causes. Instead, ABS is akin to a specific shock that affects giving to health charities. We find a significant increase in the probability of giving to health charities, with no change for other charity types. Accompanying this is an increase in amounts given to health charities, which comes at the expense of non-health, non-religious charities. The impact is greatest in the year after the health shock, attenuating thereafter.

Globally, Indigenous populations experience poorer health but use less primary healthcare than their non-Indigenous counterparts. In 2010, the Australian government introduced a targeted reform aimed at reducing these disparities. The reform reduced, or abolished prescription medicine co-payments and provided financial incentives for GPs to better manage chronic disease care for Indigenous peoples. Exploiting the framework of a natural experiment, we investigate how the reform affected these health disparities in primary and specialist healthcare utilization using longitudinal administrative data from 75,826 Australians, including 1896 Indigenous peoples, with cardiovascular disease. The differences-in-differences estimates indicate that the reform increased primary healthcare use among Indigenous peoples, including 12.9% more prescription medicines, 6.6% more GP services, and 34.0% more chronic disease services, but also reduced specialist attendances by 11.8%. Increases in primary care were larger for those who received the largest co-payment relief and lived in metropolitan regions, whereas the reduction in specialist attendances was concentrated among lower income Indigenous patients. Affirmative action can reduce inequalities in Indigenous use of primary healthcare, albeit careful design is required to ensure that benefits are equitable and do not lead to substitution away from valuable, or necessary, care.

This paper establishes a unified framework to fully account for the changing social gradient over the lifecycle in terms of a sufficient set of mobility indices characterizing the coevolution of socioeconomic status and health within each of a series of overlapping cohorts. We proceed to demonstrate the impact of selective mortality on health inequality changes, making use of a counterfactual health distribution for the start of the study period that leaves out those who are known to die before the end. Specifically, initial differences between the average health and educational attainment rank of survivors and nonsurvivors are found in our empirical study to be an increasingly important factor explaining changes in the education-health gradient in older cohorts in Great Britain. Our identification strategy has the advantage that it does not require the imputation of the "would be" health of nonsurvivors, which if carried out using inverse probability weighting procedures-as in several previous studies-is shown to bias estimates of this direct effect of selective mortality toward zero. Parallel results for the income-health gradient exhibit stronger confounding influences due to a number of other factors given that income is a less stable indicator of socioeconomic status in adulthood.

Introduction This study estimates the extent to which individuals’ smoking cessation and relapse patterns are associated with the smoking behavior of their household members. Aims and Methods Longitudinal data on household members’ smoking behavior was sourced from a representative sample of 12 723 Australians who ever reported smoking between 2001 and 2019. Controlling for a rich set of confounders, multivariate regression analyses were used to predict the likelihood of smoking cessation and relapse given other household members’ smoking status and their relationship type. The models were then used to forecast smoking prevalence over 10 years across different household types. Results Individuals living with a smoking spouse were less likely to quit (OR 0.77 [95% CI 0.72;0.83]) and more likely to relapse (OR 1.47 [95% CI 1.28;1.69]) compared to those living with nonsmoking spouses. Subsequently, the proportion of smokers living with other smoking household members increased by 15% between 2011 and 2019. A 10-year forecast using the smoking cessation and relapse models predicts that, on average, smokers living with nonsmokers will reduce by 43%, while those living alone or with a smoking partner will only reduce by 26% and 28% respectively. Conclusions Over time, those who are still smoking are more likely to live with other smokers. Therefore, the current cohort of smokers is increasingly less likely to quit and more likely to relapse. Smoking projection models that fail to account for this dynamic risk may overstate the downstream health benefits and health cost savings. Interventions that encourage smoking cessation at the household level, particularly for spouses, may assist individuals to quit and abstain from smoking. Implications The current and future paradigm shift in the smoking environment suggests that smoking cessation and relapse prevention policies should consider household structure. Policies designed to affect smoking at the household level are likely to be particularly effective. When estimating the long-term benefits of current smoking policies intrahousehold smoking behavior needs to be considered.

Despite the high rates of mental disorder in adolescents and young adults, treatment utilisation is low. Using Australian longitudinal administrative and survey data, we show an increasing proportion of young people are accessing nervous system scripts as they age. Younger cohorts have increasingly accessed these scripts earlier; usage is generally higher among disadvantaged groups and in regions with better mental health service access. Less than half of all young adults facing very high psychological distress in 2018 had recently accessed mental health care. Instead of professional help, young people turn to friends and family for help with personal and emotional problems.

Purpose This paper aims to determine whether a single session of a motivational interview (MI) reduces smoking relapse amongst people released from smoke-free prisons. Design/methodology/approach This study sought to recruit 824 ex-smokers from 2 smoke-free prisons in the Northern Territory, Australia. Participants were randomised to receive either one session (45–60 min) face-to-face MI intervention 4–6 weeks prior to release or usual care (UC) without smoking advice. The primary outcome was continuous smoking abstinence verified by exhaled carbon monoxide test ( Findings From April 2017 to March 2018, a total of 557 participants were randomised to receive the MI (n = 266) or UC (n = 291), with 75% and 77% being followed up, respectively. There was no significant between-group difference in continuous abstinence (MI 8.6% vs UC 7.4%, risk ratio = 1.16, 95%CI 0.67∼2.03). Of all participants, 66.9% relapsed on the day of release and 90.2% relapsed within three months. On average, participants in the MI group smoked one less cigarette daily than those in the UC within the three months after release (p Research limitations/implications A single-session of MI is insufficient to reduce relapse after release from a smoke-free prison. However, prison release remains an appealing time window to build on the public health benefit of smoke-free prisons. Further research is needed to develop both pre- and post-release interventions that provide continuity of care for relapse prevention. Originality/value This study is the first Australian randomised controlled trial to evaluate a pre-release MI intervention on smoking relapse prevention amongst people released from smoke-free prisons.

Good retirement planning requires accurate estimation of the time horizon, that is, the lifespan. People may overestimate or underestimate their lifespan and, as a result, under- or over-save for their retirement. Determining to what extent a person overestimates or underestimates their lifespan requires the separation of private information (e.g. family longevity history) and misinformation (e.g. misperception of one’s related cohort life expectancy). This paper proposes a method to identify and separate the effects of private information and misinformation on one’s subjective life expectancy. The method requires the person to provide their subjective life expectancy estimations for not only themselves but also for their peers. We apply the method to a sample of about 700 Chinese adults aged 40 and above. We find that misinformation leads the respondents to overestimate their remaining lifespan by 18% on average. We also find that private information leads the respondents in our sample to believe that their remaining lifespan will be 12% longer on average than their peers of the same age and gender. However, the dispersion of the individual estimates is large, meaning that some people may significantly overestimate their lifespan while others significantly underestimate. Also, as age increases, the relative importance of private information in the subjective life expectancy increases as compared to misinformation.

OBJECTIVE To develop a patient-level simulation model for predicting lifetime health outcomes of patients with type 1 diabetes and as a tool for economic evaluation of type 1 diabetes treatment based on data from a large, longitudinal cohort. RESEARCH DESIGN AND METHODS Data for model development were obtained from the Swedish National Diabetes Register. We derived parametric proportional hazards models predicting absolute risk of diabetes complications and death based on a wide range of clinical variables and history of complications. We used linear regression models to predict risk factor progression. Internal validation was performed, estimates of life expectancies for different age-sex strata were computed, and the impact of key risk factors on life expectancy was assessed. RESULTS The study population consisted of 27,841 patients with type 1 diabetes with a mean duration of follow-up of 7 years. Internal validation showed good agreement between predicted and observed cumulative incidence of death and 10 complications. Simulated life expectancy was approximately 13 years lower than that of the sex- and age-matched general population, and patients with type 1 diabetes could expect to live with one or more complications for approximately 40% of their remaining life. Sensitivity analysis showed the importance of preventing renal dysfunction, hypoglycaemia and hyperglycaemia, and lowering HbA1c in reducing the risk of complications and death. CONCLUSIONS Our model was able to simulate risk factor progression and event histories that closely match the observed outcomes, and project events occurring over patients’ lifetimes. The model can serve as a tool to estimate the impact of changing clinical risk factors on health outcomes to inform economic evaluations of interventions in type 1 diabetes.

Objective: To determine the government and out‐of‐pocket community costs (out‐of‐hospital medical services and prescription medicines) associated with screen‐detected and community‐detected cancers (i.e. cancers detected outside of Australia's organised screening program [BreastScreen]). Methods: We analyse administrative data on government‐subsidised medical services and prescription medicines for 568 Victorian women diagnosed with breast cancer or ductal carcinoma in situ (DCIS). Using multivariable regression analysis, we estimate the government and out‐of‐pocket community costs incurred in the three years after diagnosis for screen‐detected cancers and community‐detected cancers. Additionally, we estimate the government costs associated with diagnosis within and outside of BreastScreen. Results: Average government costs for breast cancer diagnosis were similar within and outside of BreastScreen [$808 (lower limit 676; upper limit 940) vs $837 (95%CI 671; 1,003) respectively]; however, women with community‐detected cancers incurred an additional $254 (95%CI 175; 332) out‐of‐pocket. Controlling for differences in known cancer characteristics, compared to screen‐detected cancers, community‐detected breast cancers were associated with an additional $2,622 (95%CI 644; 4,776) in government expenditure in the three years following diagnosis. Adverse cancer characteristics that were more prevalent in community‐detected cancers (high grade, lymph node involvement, HER2 positive receptor status) were associated with increased government and out‐of‐pocket costs. Conclusions: Community‐detected breast cancers were associated with increased government and out‐of‐pocket costs. Implications for public health: These costs should be considered when evaluating current and alternative breast cancer screening strategies.

Background: International comparisons of social inequalities in health outcomes and behaviors are challenging. Due to the level of disaggregation often required, data can be sparse and methods to make adequately powered comparisons are lacking. We aimed to illustrate the value of a hierarchical Bayesian approach that partially pools country-level estimates, reducing the influence of sampling variation and increasing the stability of estimates. We also illustrate a new way of simultaneously displaying the uncertainty of both relative and absolute inequality estimates. Methods: We used the 2014 European Social Survey to estimate smoking prevalence, absolute, and relative inequalities for men and women with and without disabilities in 21 European countries. We simultaneously display smoking prevalence for people without disabilities (x-axis), absolute (y-axis), and relative inequalities (contour lines), capturing the uncertainty of these estimates by plotting a 2-D normal approximation of the posterior distribution from the full probability (Bayesian) analysis. Results: Our study confirms that across Europe smoking prevalence is generally higher for people with disabilities than for those without. Our model shifts more extreme prevalence estimates that are based on fewer observations, toward the European mean. Conclusions: We demonstrate the utility of partial pooling to make adequately powered estimates of inequality, allowing estimates from countries with smaller sample sizes to benefit from the increased precision of the European average. Including uncertainty on our inequality plot provides a useful tool for evaluating both the geographical patterns of variation in, and strength of evidence for, differences in social inequalities in health.

Social impact bonds (SIBs) have emerged as an innovative financing mechanism. This paper explores how health SIBs align with investors’ expectations and the conditions required to attract investors...

AimsTo examine the association between household members and their tobacco smoking behaviour on patterns of smoking cessation and relapse.Design and participantsData was sourced from 19 waves (years 2001 to 2019) of the nationally representative Household Income and Labour Dynamics in Australia (HILDA) survey, with all household members 15 years or older completing the survey annually. The final sample included, on average, 3,056 ex-smokers and 2,612 smokers per wave.MeasurementsSelf-reported annual smoking status was used to construct measures of smoking cessation and relapse. Information on household structure and relationships was then used to develop variables describing the presence of household members and their smoking status by relationship to the individual (i.e., child, parent, spouse, sibling, or other). Multivariate regression analyses were then used to predict the likelihood of smoking cessation and relapse controlling for the presence of other household members and their smoking status, sociodemographic characteristics, number of cigarettes smoked per day, previous quit attempts, and years abstained from smoking.FindingsIndividuals that lived with non-smokers were more likely to quit [OR1.22 (95%CI 1.11;1.34)] relative to those living alone. However, this favourable association was negated if living with another smoker, which was associated with a reduced likelihood of smoking cessation [OR0.77 (95%CI 0.72;0.83)] and a higher likelihood of relapse [1.37 (95%CI 1.22;1.53)]. In particular, living with a spouse or parent that smoked reduced the likelihood of smoking cessation [OR0.71 (95%CI 0.65;0.78) and OR0.71 (95%CI 0.59;0.84), respectively] and increased the likelihood of relapse [OR1.47 (95%CI 1.28;1.69) and OR1.39 (95%CI 1.00;1.94) respectively] relative to living with their non-smoking counterparts.ConclusionsHousehold composition and intrahousehold smoking behaviour should be considered when delivering, or estimating the benefits of, smoking cessation interventions. Interventions which encourage smoking cessation at the household level may assist individuals to quit and abstain from smoking.

Little is known about how patients dynamically respond to a forthcoming reduction in health care out-of-pocket prices. Using a kinked Donut Regression Discontinuity design with kinks entering and exiting the donut, we evaluate a Swedish cost-sharing policy, where primary care out-of-pocket prices were eliminated at age 85. We find evidence of forward-looking moral hazard with older adults delaying primary care visits up to four months before the out-of-pocket elimination and shifting these visits until shortly after. These health care delays are driven by non-urgent care: non-physician visits, planned visits and follow up visits. We find no evidence of severe negative health effects in the short-term as a result of the delay. Contrary to our finding of forward-looking behavior with respect to out-of-pocket prices, we do not find evidence of typical moral hazard, as we do not find a persistent increase in primary health care use after the copayment elimination.

Background Following pandemic-related work loss, some people could return to work as restrictions eased, whilst localised lockdowns resulted in further loss of work. The long-term health effects of work loss within the pandemic remain unexplored, in addition to whether any health effects are persistent upon returning to work. Methods A prospective longitudinal cohort study of 2603 Australians monitored changes in health and work across four surveys during March-December 2020. Outcomes described psychological distress, and mental and physical health. Linear mixed regression models examined associations between changes in health and experiences of work loss, and return to work, over time. Results Losing work during the early pandemic stages was associated with long-term poorer mental health, which began to recover over time. Physical health deteriorated over time, greater for people not working at baseline. Being out of work was associated with poorer mental health, but better physical health. These effects were larger for people that had recently lost work than for people with sustained work loss, and retaining employment played a protective role. Conclusions Work cessation during the pandemic led to poor health outcomes and had long-lasting effects. Returning to work benefits mental health but may reduce physical activity in the short-term. We encourage the provision of accessible mental health supports immediately following loss of work, and for people with prolonged work loss. Key messages Remaining employed whilst not working partly ameliorates negative mental health impacts. Those experiencing persistent work loss, and the newly out-of-work, are most vulnerable to ill mental health.

Background In response to the second wave of COVID-19 in Australia a 4 month community-wide lockdown resulted in Victoria, Australia. We explored the health impacts during lockdown and following its conclusion. Methods A cohort of 898 working-age Australians enrolled in a national longitudinal cohort study, completing surveys prior to, during, and following a Victorian lockdown during the southern hemisphere winter and early spring 2020. Mixed linear regression models examined health outcomes during and following the lockdown. Generalised estimating equations assessed changes in several determinants of health such as social interactions, engagement in work and finances. Results The Victorian lockdown had negative consequences for mental health and increased levels of psychological distress. These health impacts coincided with greater social isolation and cessation of work. Following the conclusion of lockdown, outcomes assessing mental health, work and social interactions had recovered to an extent whereby no significant long-lasting effects were identified compared to pre-lockdown conditions. Conclusions Extended community lockdowns have adverse health consequences. Governments should weigh the potential health impacts of lockdown with the benefits of reducing COVID-19 transmission. Services and programs to reduce the negative impacts of lockdown may include increases in mental health care, encouraging safe social interactions and financial support to maintain employment relationships. Longer-term follow-up is required to identify any persistent health effects of community lockdowns. Key messages Lockdowns result in adverse health consequences, and some quickly recover. Timely services and programs are encouraged to reduce negative impacts of lockdowns such as mental health supports and promoting safe interactions.

Background The positive cross-sectional association between health and SES often strengthens at younger ages before peaking at middle ages and then weakening at older ages. Selective mortality is a possible reason for the weakening relationship at older ages but current evidence for this is limited. Methods This paper uncovers the changing nature of the inter-dependence between SES and health over the lifecycle by further developing and applying longitudinal inequality decomposition techniques which account for mortality. We examine changes in SES-related health inequality for rolling age cohorts by gender for Australia (using the Household, Income and Labour Dynamics in Australia (HILDA) survey) and the United Kingdom (using the Understanding Society survey). Results We find for young men in both countries that the simultaneous co-movement in both health and income plays the major role in increasing health inequalities. At middle ages the poor start to lose health more quickly than the rich but at older ages selective mortality plays the major role with the poor more likely to die than the rich which also has an indirect effect of making morbidity losses seem less concentrated among the poor. Conclusions Selective mortality plays a major role in weakening the relationship between SES and health at older ages. Past studies have missed identifying the full effect of selective mortality. Key messages SES-related health inequalities accumulate throughout the lifecycle, even in older ages.

Background There is increasing interest in risk-based breast cancer screening, including interventions to improve outcomes for women with mammographically dense breasts. Methods Policy1-Breast is a continuous-time, multiple-cohort micro-simulation whole-population model which incorporates breast cancer risk, life-course breast density, menopause, hormone therapy use and screening participation. Outcomes include cancer diagnoses and characteristics (invasive/DCIS, tumour size, grade), mode of detection (screen-detected/interval/other) and mortality (breast cancer and other cause). Policy1-Breast validates well against key observed clinical outcomes in Australia. We estimate changes in outcomes within and outside the BreastScreen program upon the introduction of a hypothetical screening test with improved sensitivity for women with dense breasts. Results We estimate that introducing in year 2020 a screening test for women in the highest quintile of breast density at age 50 that halves the masking effect of their breast density would, by 2026-2030, increase diagnosis rates of population-level invasive cancers ( 10%) and screen-detected cancers (20%) and decrease rates of interval cancers (17%) and community-detected cancers (6%). Conclusions Targeted screening tests with improved sensitivity for women with dense breasts are expected to markedly reduce interval cancers and other cancers diagnosed outside the BreastScreen program, while increasing all cancer diagnoses due to increased rates of screen-detected cancers. Key messages Specialised breast cancer screening tests directed at women with very high breast density are expected to reduce interval cancers and increase overall cancer diagnoses. Population simulation models such as Policy1-Breast can complement trial evidence by evaluating a range of scenarios and estimating short and long-term implications.

Objectives To determine health impacts during, and following, an extended community lockdown and COVID-19 outbreak in the Australian state of Victoria, compared with the rest of Australia. Methods A national cohort of 898 working-age Australians enrolled in a longitudinal cohort study, completing surveys before, during, and after a 112-day community lockdown in Victoria (8 July– 27 October 2020). Outcomes included psychological distress, mental and physical health, work, social interactions and finances. Regression models examined health changes during and following lockdown. Results The Victorian lockdown led to increased psychological distress. Health impacts coincided with greater social isolation and work loss. Following the extended lockdown, mental health, work and social interactions recovered to an extent whereby no significant long-lasting effects were identified in Victoria compared to the rest of Australia. Conclusion The Victorian community lockdown had adverse health consequences, which reversed upon release from lockdown. Governments should weigh all potential health impacts of lockdown. Services and programs to reduce the negative impacts of lockdown may include increases in mental health care, encouraging safe social interactions and supports to maintain employment relationships.

The reporting of only relative inequalities is decreasing and other inequality invariance criteria are often being considered simultaneously. Having multiple measures with potentially different conclusions on whether inequality has increased or decreased complicates communicating what these results imply about the evolution of income inequality. To facilitate understanding this evolution, we highlight the advantage of visualizing in a single graph the relationship between changes in mean income and the development of inequality according to multiple inequality invariance criteria. Not presenting how these entities relate may mislead policy makers about the evolution of income inequality and its potential causes.

Importance Cytisine is more effective than placebo and nicotine replacement therapy for smoking cessation. However, cytisine has not been tested against the most effective smoking cessation medication, varenicline, which is associated with adverse events known to lead to discontinuation of therapy. Objective To examine whether standard cytisine treatment (25 days) was at least as effective as standard varenicline treatment (84 days) for smoking cessation. Design, Setting, and Participants This noninferiority, open-label randomized clinical trial with allocation concealment and blinded outcome assessment was undertaken in Australia from November 2017 through May 2019; follow-up was completed in January 2020. A total of 1452 Australian adult daily smokers willing to make a quit attempt were included. Data collection was conducted primarily by computer-assisted telephone interview, but there was an in-person visit to validate the primary outcome. Interventions Treatments were provided in accordance with the manufacturers’ recommended dosage: cytisine (n = 725), 1.5-mg capsules taken 6 times daily initially then gradually reduced over the 25-day course; varenicline (n = 727), 0.5-mg tablets titrated to 1 mg twice daily for 84 days (12 weeks). All participants were offered referral to standard telephone behavioral support. Main Outcomes and Measures The primary outcome was 6-month continuous abstinence verified using a carbon monoxide breath test at 7-month follow-up. The noninferiority margin was set at 5% and the 1-sided significance threshold was set at .025. Results Among 1452 participants who were randomized (mean [SD] age, 42.9 [12.7] years; 742 [51.1%] women), 1108 (76.3%) completed the trial. Verified 6-month continuous abstinence rates were 11.7% for the cytisine group and 13.3% for the varenicline group (risk difference, −1.62% [1-sided 97.5% CI, −5.02% to ∞];P = .03 for noninferiority). Self-reported adverse events occurred less frequently in the cytisine group (997 events among 482 participants) compared with the varenicline group (1206 events among 510 participants) and the incident rate ratio was 0.88 (95% CI, 0.81 to 0.95;P = .002). Conclusions and Relevance Among daily smokers willing to quit, cytisine treatment for 25 days, compared with varenicline treatment for 84 days, failed to demonstrate noninferiority regarding smoking cessation. Trial Registration anzctr.org.au Identifier:ACTRN12616001654448

Universal suicide education and awareness training in schools are promising suicide prevention initiatives. This study aims to evaluate a suicide awareness training (safeTALK) and to model potential return on investment (ROI) on a population basis. SafeTALK, comprises a 3-h education session, and has been delivered to secondary school students (aged 15–16 years) in Mackay, located in the Australian state of Queensland. Evaluation consisted of two phases, ex-post and ex-ante. Phase I was a pre-post, follow-up analysis using a mixed-method questionnaire administered immediately prior (Time 1), immediately after (Time 2), and 4 weeks after training (Time 3). Phase II involved decision analytic modelling comparing safeTALK to the status quo. ROI was modelled using Markov chains for a hypothetical population of students aged 15–19 years in Mackay (n = 2561; suicide rate 78.1 per 100,000), Queensland (n = 296,287; 10.2) and Australia (n = 1,421,595; 8.3). Model parameters, including rates of hospitalised self-harm and suicide, cost implications and effectiveness of safeTALK were drawn from published literature. The baseline model adapted a health and justice system’s perspective, with an alternative model incorporating a societal perspective. All costs were adjusted to reflect AU$2017–2018. Students reported seeking help mostly from friends (79%) or parents (68%); in the last 6 months 61% considered another student’s behaviour as suicidal, but only 21% reported asking about this. The main barriers to help-seeking were (i) being too embarrassed, (ii) shy or (iii) being judged. Students who attended safeTALK gained suicide-related knowledge (p

Background To achieve the World Health Organization hepatitis C virus (HCV) elimination targets, it is essential to increase access to direct-acting antivirals (DAAs), especially among people who inject drugs (PWID). We aimed to determine the effectiveness of providing DAAs in primary care, compared with hospital-based specialist care. Methods We randomized PWID with HCV attending primary care sites in Australia or New Zealand to receive DAAs at their primary care site or local hospital (standard of care [SOC]). The primary outcome was to determine whether people treated in primary care had a noninferior rate of sustained virologic response at Week 12 (SVR12), compared to historical controls (consistent with DAA trials at the time of the study design); secondary outcomes included comparisons of treatment initiation, SVR12 rates, and the care cascade by study arm. Results We recruited 140 participants and randomized 136: 70 to the primary care arm and 66 to the SOC arm. The SVR12 rate (100%, 95% confidence interval [CI] 87.7–100) of people treated in primary care was noninferior when compared to historical controls (85% assumed). An intention-to-treat analysis revealed that the proportion of participants commencing treatment in the primary care arm (75%, 43/57) was significantly higher than in the SOC arm (34%, 18/53; P < .001; relative risk [RR] 2.48, 95% CI 1.54–3.95), and the proportion of participants with SVR12 was significantly higher in the primary care arm, compared to in the SOC arm (49% [28/57] and 30% [16/53], respectively; P = .043; RR 1.63, 95% CI 1.0–2.65). Conclusions Providing HCV treatment in primary care increases treatment uptake and cure rates. Approaches that increase treatment uptake among PWID will accelerate elimination strategies. Clinical Trials Registration NCT02555475.

Policy decisions regarding breast cancer screening and treatment programmes may be misplaced unless the decision process includes the appropriate utilities and disutilities of mammography screening and its sequelae. The objectives of this study were to critically review how economic evaluations have valued the health states associated with breast cancer screening, and appraise the primary evidence informing health state utility values (cardinal measures of quality of life). A systematic review was conducted up to September 2018 of studies that elicited or used utilities relevant to mammography screening. The methods used to elicit utilities and the quality of the reported values were tabulated and analysed narratively. 40 economic evaluations of breast cancer screening programmes and 10 primary studies measuring utilities for health states associated with mammography were reviewed in full. The economic evaluations made different assumptions about the measures used, duration applied and the sequalae included in each health state. 22 evaluations referenced utilities based on assumptions or used measures that were not methodologically appropriate. There was significant heterogeneity in the utilities generated by the 10 primary studies, including the methods and population used to derive them. No study asked women to explicitly consider the risk of overdiagnosis when valuing the health states described. Utilities informing breast screening policy are restricted in their ability to reflect the full benefits and harms. Evaluating the true cost-effectiveness of breast cancer screening will remain problematic, unless the methodological challenges associated with valuing the disutilities of screening are adequately addressed.

Background Engagement in work is an important determinant of health. In response to the COVID-19 pandemic, public health measures imposed to reduce viral transmission resulted in large-scale loss of work during the early stages of the pandemic, contributing to declined mental and physical health. As the pandemic unfolded, the Australian economy began to recover and some people could return to work, whilst localised lockdowns resulted in further loss of work for others. The long-term health effects of work loss remain unexplored within the COVID-19 pandemic context, in addition to whether any health effects are persistent upon returning to work. Methods A prospective longitudinal cohort study of 2603 participants across Australia monitored changes in health and work between March and December 2020, with participants completing surveys at baseline and 1, 3 and 6 months later. Outcomes described psychological distress, and mental and physical health. Linear mixed regression models examined associations between changes in health and experiences of work loss, and return to work, over time. Results Losing work during the early stages of the pandemic was associated with long-term poorer mental health, which began to recover over time as some returned to work. Physical health deteriorated over time, greater for people not working at baseline. Being out of work was associated with poorer mental health, but better physical health. These effects were larger for people that had recently lost work than for people with sustained work loss, and retaining employment played a protective role. Generally, returning to work resulted in poorer physical health and improvements in mental health, although this depended on the broader context of changes in work. Conclusions Work cessation during the pandemic led to poor health outcomes and had long-lasting effects. Returning to work benefits mental health but may reduce physical activity in the short-term. We encourage the provision of accessible mental health supports and services immediately following loss of work, and for people with prolonged forms of work loss. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN12620000857909.

Governments and health insurers often make funding decisions based on health gains from randomised controlled trials. These decisions are inherently uncertain because health gains in trials may not translate to practice owing to differences in the population, treatment use and setting. Post-market analysis of real-world data can provide additional evidence but estimates from standard matching methods may be biased when unobserved characteristics explain whether a patient is treated and their outcomes. We propose a new untreated matching approach that can reduce this bias. Our approach utilises the outcomes of contemporaneous untreated patients to improve the matching of treated and historical control patients. We assess the performance of this new approach compared to standard matching using a simulation study and demonstrate the steps required using a funding decision for prostate cancer treatments in Australia. Our simulation study shows that our new matching approach eliminates nearly all bias when unobserved treatment selection is related to outcomes, and outperforms standard matching in most scenarios. In our empirical example, standard matching overestimated survival by 15% (95% confidence interval 2–34) compared to our untreated matching approach. The health gains estimated using our approach were slightly lower than expected based on the trial evidence, but we also found evidence that in practice prescribers ceased prior therapies earlier, treated a more vulnerable population and continued treatment for longer. Our untreated matching approach offers researchers a new tool for reducing uncertainty in healthcare funding decisions using real-world data.

Purpose To determine if losing work during the COVID-19 pandemic is associated with mental and physical health status. To determine if social interactions and financial resources moderate the relationship between work loss and health. Methods Participants were Australians aged 18 + years that were employed in paid work prior to the COVID-19 pandemic who responded to an online or telephone survey from 27th March to 12th June 2020 as part of a prospective longitudinal cohort study. Outcome measures include Kessler-6 score > 18 indicating high psychological distress, and Short Form 12 (SF-12) mental health or physical health component score

Background:Although evaluations of breast cancer screening programs frequently estimate quality-adjusted life-year (QALY) losses by stage, other breast cancer characteristics influence treatment and vary by mode of detection - i.e. whether the cancer is detected through screening (screen-detected), between screening rounds (interval-detected) or outside screening (community-detected). Here, we estimate the association between early-stage invasive breast cancer (ESIBC) characteristics and treatment-related QALY losses.Methods:Using clinicopathological and treatment information from 675 women managed for ESIBC, we estimated the average five-year treatment-related QALY loss by detection group. We then used regression analysis to estimate the extent to which known cancer characteristics and the detection mode, are associated with treatment and treatment-related QALY losses.Results:Community-detected cancers had the largest QALY loss (0.76 QALYs [95% CI 0.73;0.80]), followed by interval-detected cancers (0.75 QALYs [95% CI 0.68;0.82]) and screen-detected cancers (0.69 QALYs [95%CI 0.67;0.71]). Adverse prognostic factors more common in community-detected and interval-detected breast cancers (large tumours, lymph node involvement, high grade) were largely associated with QALY losses from mastectomies and chemotherapy. Receptor-positive subtypes, more common in screen-detected cancers, were associated with QALY losses related to endocrine therapy.Conclusions:The associations between ESIBC characteristics and treatment-related QALY losses should be considered when evaluating breast cancer screening and treatment strategies.

ObjectiveTo determine if losing work during the COVID-19 pandemic is associated with mental and physical health. To determine if social interactions and financial resources moderate the relationship between work loss and health.DesignBaseline data from a prospective longitudinal cohort study.SettingAustralia, 27th March to 12th June 2020.ParticipantsAustralians aged 18+ years, employed in a paid job prior to the COVID-19 pandemic who responded to an online or telephone survey.Main Outcome MeasuresKessler-6 score > 18 indicating high psychological distress. Short Form 12 (SF-12) mental health or physical health component score < = 45 indicating poor mental or physical health.Results2,603 respondents including groups who had lost their job (N = 541), were not working but remained employed (N = 613), were working less (N = 789) and whose work was unaffected (N = 789). Three groups experiencing work loss had greater odds of high psychological distress (AOR = 2.22–3.66), poor mental (AOR = 1.78–2.27) and physical health (AOR = 2.10–2.12) than the unaffected work group. Poor mental health was more common than poor physical health. The odds of high psychological distress (AOR = 5.43–8.36), poor mental (AOR = 1.92–4.53) and physical health (AOR = 1.93–3.90) were increased in those reporting fewer social interactions or less financial resources.ConclusionLosing work during the COVID-19 pandemic is associated with mental and physical health problems, and this relationship is moderated by social interactions and financial resources. Responses that increase financial security and enhance social connections may partially alleviate the health impacts of work loss.RegistrationAustralian New Zealand Clinical Trials Registry: ACTRN12620000857909.

IntroductionThis study estimated the extent of psychological distress among people losing work during the coronavirus disease of 2019 (COVID-19) pandemic in Australia, and examined associations between distress, nature of work loss and degree of social interaction.MethodsData were from a baseline online survey of an inception cohort recruited in the weeks following the introduction of physical distancing and movement restrictions to contain the spread of COVID-19 in Australia. These restrictions resulted in widespread unemployment and working hour reduction. Psychological distress was measured using the Kessler-6 scale. Data on nature of work loss, social interactions, demographic, job and occupational characteristics were also collected. Regression modelling was conducted to determine the relationship between work loss, social interactions and psychological distress, accounting for confounders.ResultsAmong the 551 study participants 31% reported severe psychological distress, 35% in those with job loss and 28% in those still employed but working less. Those who had significantly greater odds of high psychological distress were younger, female, had lost their job and had lower social interactions. The relationship between job loss and distress became non-significant when financial stress, and occupation were included in the regression model, but the protective effect of higher social interactions remained significant.DiscussionThere was a high prevalence of psychological distress in people losing work during the coronavirus pandemic. Age, gender, job loss and social interactions were strongly associated with distress. Interventions that promote social interaction may help to reduce distress during among people losing work during the COVID-19 pandemic.

Self-assessed health (SAH) is often used in health econometric models as the key explanatory variable or as a control variable. However, there is evidence questioning its test-retest reliability, with up to 30% of individuals changing their response. Building on recent advances in the econometrics of misclassification, we develop a way to consistently estimate and account for misclassification in reported SAH by using data from a large representative longitudinal survey where SAH was elicited twice. From this we gain new insights into the nature of SAH misclassification and its potential for biasing health econometric estimates. The results from applying our approach to nonlinear models of long-term mortality and chronic morbidities reveal that there is substantial heterogeneity in misclassification patterns. We find that adjusting for misclassification is important for estimating the impact of SAH. For other explanatory variables of interest, we find significant but generally small changes to their estimates when SAH misclassification is ignored.

Aims: To test the effectiveness of a theoretically based text‐message intervention to reduce binge drinking among socially disadvantaged men. Design: A multi‐centre parallel group, pragmatic, individually randomized controlled trial. Setting: Community‐based study conducted in four regions of Scotland. Participants: A total of 825 men aged 25–44 years recruited from socially disadvantaged areas who had two or more episodes of binge drinking (> 8 UK units on a single occasion) in the preceding 28 days: 411 men were randomized to the intervention and 414 to the control. Intervention and comparator: A series of 112 interactive text messages was delivered by mobile phone during a 12‐week period. The intervention was structured around the Health Action Process Approach, a comprehensive model which allows integration of a range of evidence‐based behaviour change techniques. The control group received 89 texts on general health, with no mention of alcohol or use of behaviour change techniques. Measurements: The primary outcome measure was the proportion of men consuming > 8 units on three or more occasions (in the previous 28 days) at 12 months post‐intervention. Findings: The proportion of men consuming > 8 units on three or more occasions (in the previous 28 days) was 41.5% in the intervention group and 47.8% in the control group. Formal analysis showed that there was no evidence that the intervention was effective [odds ratio (OR) = 0.79, 95% confidence interval (CI) = 0.57–1.08; absolute reduction 5.7%, 95% CI = −13.3 to 1.9]. The Bayes factor for this outcome was 1.3, confirming that the results were inconclusive. The retention was high and similar in intervention (84.9%) and control (86.5%) groups. Most men in the intervention group engaged with the text messages: almost all (92%) replied to text messages and 67% replied more than 10 times. Conclusions: A theoretically based text‐messaging intervention aimed at reducing binge drinking in disadvantaged men was not found to reduce prevalence of binge drinking at 12‐month follow‐up.