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

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

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

Miller and Xie (2020) raise a call to action on creating a sustainable Canadian healthcare system as part of a more just and sustainable economic model. This commentary explores the economic dimensions of this call to action. It provides a brief overview of relevant concepts and insights from emerging schools of economic thinking, and contemplates challenges and opportunities for health system sustainability as the economic consequences of COVID-19 play out in coming years.

BACKGROUND In March 2020, the Australian Government expanded general practitioner (GP) telehealth services in response to the coronavirus disease 2019 pandemic. OBJECTIVE This study sought to assess utilisation patterns of GP telehealth services in response to changing circumstances (before and during the COVID-19 pandemic, with or without lockdown) in regional Victoria, Australia. METHODS We conducted a secondary analysis of monthly Medicare claims data from July 2019 to June 2021 from 140 regional GP practices in western Victoria. The longitudinal patterns of proportion of GP telehealth consultations stratified by type of consultation (videoconference vs. telephone) and by geographical, consumer and consultation characteristics were analysed. RESULTS Telehealth comprised 25.8% of GP consultations over the two-year period (n total = 2,025,615). After the introduction of the Australian telehealth expansion policy in March 2020, there was a rapid uptake in GP telehealth services (from 0% to 15% of all consultations), with a peak in August 2020 (55%). Thereafter, utilisation declined steadily to 31% in January 2021 and tapered off to 28% in June 2021. Telephone services and shorter consults were the most dominant form, and those aged 15-64 years had higher telehealth utilisation rates than younger or older age groups. The proportion of video consultations was higher during periods with government-imposed lockdown, and higher in the most socioeconomically advantaged areas compared to less socioeconomically advantaged areas. CONCLUSIONS Our findings support the continuation of telehealth use in rural and regional Australia post-pandemic. Future policy must identify mechanisms to reduce existing equity gaps in video consultations and consider patient- and system-level implications of the dominant use of short telephone consults.

Introduction The prevalence of obesity is increasing in developed countries, including Australia. There is evidence that bariatric surgery is effective in losing weight and reducing risk of chronic diseases. However, access to bariatric surgery remains limited in the public health sector. Method We modelled population-based estimates of the likely numbers of people eligible for bariatric surgery in Australia using the recent Australian New Zealand Metabolic and Obesity Surgery Society (ANZMOSS) framework and estimated the potential costs that would be incurred from primary and subsequent reoperations in both public and private sector. Results The annual number of newly eligible patients is expected to rise, and hence the gap in demand is increasing relative to current baseline supply. If a 5-year program to treat all currently eligible patients was implemented, the maximum yearly demand is projected to be 341,343 primary surgeries, more than eight times the existing capacity of public and private sector, which can only offer 41,534 surgeries/year. A nine-fold increase is expected if we treat currently eligible patients over a 5-year program and all newly eligible patients as they occur each year. Conclusion Our results highlighted the currently highly skewed distribution of bariatric surgeries between the private and public sectors. Improving access would bring substantial benefits to many Australians, given the demonstrated cost-effectiveness and cost savings. This requires a major increase in resourcing for publicly-funded access to bariatric surgery in the first instance. A national review of priorities and resourcing for all modes of obesity treatment is required in Australia. Graphical abstract

Background Concerns have grown that post-acute sequelae of COVID-19 may affect significant numbers of survivors. However, the analyses used to guide policy-making for Australia’s national and state re-opening plans have not incorporated non-acute illness in their modelling. We, therefore, develop a model by which to estimate the potential acute and post-acute COVID-19 burden using disability-adjusted life years (DALYs) associated with the re-opening of Australian borders and the easing of other public health measures, with particular attention to longer-term, post-acute consequences and the potential impact of permanent functional impairment following COVID-19. Methods A model was developed based on the European Burden of Disease Network protocol guideline and consensus model to estimate the burden of COVID-19 using DALYs. Data inputs were based on publicly available sources. COVID-19 infection and different scenarios were drawn from the Doherty Institute’s modelling report to estimate the likely DALY losses under the Australian national re-opening plan. Long COVID prevalence, post-intensive care syndrome (PICS) and potential permanent functional impairment incidences were drawn from the literature. DALYs were calculated for the following health states: the symptomatic phase, Long COVID, PICS and potential permanent functional impairment (e.g., diabetes, Parkinson’s disease, dementia, anxiety disorders, ischemic stroke). Uncertainty and sensitivity analysis were performed to examine the robustness of the results. Results Mortality was responsible for 72-74% of the total base case COVID-19 burden. Long COVID and post-intensive care syndrome accounted for at least 19 and 3% of the total base case DALYs respectively. When included in the analysis, potential permanent impairment could contribute to 51-55% of total DALYs lost. Conclusions The impact of Long COVID and potential long-term post-COVID disabilities could contribute substantially to the COVID-19 burden in Australia’s post-vaccination setting. As vaccination coverage increases, the share of COVID-19 burden driven by longer-term morbidity rises relative to mortality. As Australia re-opens, better estimates of the COVID-19 burden can assist with decision-making on pandemic control measures and planning for the healthcare needs of COVID-19 survivors. Our estimates highlight the importance of valuing the morbidity of post-COVID-19 sequelae, above and beyond simple mortality and case statistics.

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

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

Background Chronic diseases contribute to a significant proportion (71%) of all deaths each year worldwide. Governments and other stakeholders worldwide have taken various actions to tackle the key risk factors contributing to the prevalence and impact of chronic diseases. Private health insurers (PHI) are one key stakeholders, particularly in Australian health system, and their engagement in chronic disease prevention is growing. Therefore, we investigated the impacts of chronic disease prevention interventions implemented by PHI both in Australia and internationally. Method We searched multiple databases (Business Source Complete, CINAHL, Global Health, Health Business Elite, Medline, PsycINFO, and Scopus) and grey literature for studies/reports published in English until September 2020 using search terms on the impacts of chronic disease prevention interventions delivered by PHIs. Two reviewers assessed the risk of bias using a quality assessment tool developed by Effective Public Healthcare Panacea Project. After data extraction, the literature was synthesised thematically based on the types of the interventions reported across studies. The study protocol was registered in PROSPERO, CRD42020145644. Results Of 7789 records, 29 studies were eligible for inclusion. There were predominantly four types of interventions implemented by PHIs: Financial incentives, health coaching, wellness programs, and group medical appointments. Outcome measures across studies were varied, making it challenging to compare the difference between the effectiveness of different intervention types. Most studies reported that the impacts of interventions, such as increase in healthy eating, physical activity, and lower hospital admissions, last for a shorter term if the length of the intervention is shorter. Interpretation Although it is challenging to conclude which intervention type was the most effective, it appeared that, regardless of the intervention types, PHI interventions of longer duration (at least 2 years) were more beneficial and outcomes were more sustained than those PHI interventions that lasted for a shorter period. Funding Primary source of funding was Geelong Medical and Hospital Benefits Association (GMHBA), an Australian private health insurer.

This chapter considers the implications of different ecological macroeconomic models for health and health care - "green growth", the "steady state" economy, and "degrowth". It considers health care policy under no-growth conditions (steady state or degrowth), overconsumption in health care, and areas in which health economics will need to adapt to better meet the needs of the Anthropocene era. It considers the challenge of improving the health of the world's poorest people in a post-growth era of ecological constraints. It concludes by discussing the real risk of involuntary degrowth (or collapse), and suggests some institutional measures for health care systems which might provide some protection against the worst impacts of involuntary degrowth.

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

Health is a central aspect of all conceptions of human well-being and flourishing. This chapter considers a number of contemporary challenges in human health through the lens of ecological economics, and makes suggestions for developing a more focused agenda for applying ecological economics to health. The chapter applies a framework based upon the World Health Organization’s Ten Threats to Global Health. Non-communicable diseases (NCD) overtook infectious diseases as the leading cause of deaths globally two decades ago; a significant portion of the preventable burden of NCDs is driven by harmful overconsumption, and there is growing recognition of the interlinked impacts of global syndemics such as malnutrition, obesity and climate change. Ecological economics will need to develop effective approaches to the impacts of ageing and longevity, and to persistent inequalities in health between and within nations, as understanding grows of the central role of social inequality in generating poor physical and mental health. Providing adequate access to health care in low income countries while simultaneously reducing the harmful and wasteful overconsumption of health care is a challenge to which ecological economics may be able to contribute. Climate change and environmental pollutants have significant adverse health impacts; meanwhile, the negative environmental impacts of health care systems are becoming more clearly understood. Finally, ecological economics may be well placed to contribute to addressing the twin threats of infectious diseases, pandemics and high-threat pathogens on the one hand, and of growing antimicrobial resistance on the other.

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

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

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

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

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

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

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

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

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

Acute care hospitals remain essential components of health systems in all countries, performing common functions everywhere, namely, the initial assessment and stabilization of the acutely ill patient, provision of a more definitive diagnosis, and immediate treatment. Hospitals are integrated into referral systems with other care providers in different ways in different health systems, but similar trends toward reduced inpatient bed utilization and concentration of specialized services are visible in most developed countries. Acute hospitals will need to meet the challenge of health-care-acquired infections if recent progress toward reduced hospitalization is to be maintained in future.

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

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

Objectives. To describe the costs of establishing and operating a home-based care (HBC) project providing palliative care for people with AIDS CPWA), and to project the full costs to the health care system of extending this care model.Design. Data were collected from seven sites participating in the Hospice Association of South Africa integrated community home-based care (ICHC) model, using site records, interviews with personnel, a continuity of care survey of nursing staff supervising the sites, and time logs kept by community caregivers (CCGs). The seven sites were spread across five provinces, with a mix of rural, peri-urban and urban settings.Outcome measures. Set-up (training, equipping and planning) costs per HBC site, HBC operating costs (total and average cost per patient), and average hospital inpatient, hospital outpatient and primary care clinic cost per participating patient. Estimates of scaling up this model of HBC to national roll-out are also provided.Results and conclusions. Providing palliative HBC to PWAs in their last year of life using the ICHC model costs R2 840 per patient per year. Even with this level of HBC input, patients still incurred hospital costs of R2 522 and primary care clinic costs of R1 154 per patient per year. HBC costs are increased in rural areas where a vehicle is required for staff transport. HBC shows considerable potential to deal cost-effectively with growing palliative care needs in the face of the AIDS epidemic, but we need to understand better the true extent to which HBC can substitute for hospitalisation.

Objectives: To determine the impact of the national health strategy for England, ‘Health of the Nation’ (HOTN) at the local level; the mechanisms by which this was achieved; and to provide lessons for the new strategy, ‘Saving lives: our healthier nation’. Design: Case studies. Semi-structured Interviews with key actors across a range of organisations (n=133), analysis of documents (n=189), and analysis of expenditure for the period 1991/1992 – 1996/1997. Setting: Eight randomly selected English health authorities. Main outcome measures: Perceptions and documentary evidence of the impact of HOTN on local policy and changes In expenditure. Results: Three models of implementation were Identified: strategies based directly on HOTN; HOTN plus additional elements (‘HOTN plus’); and strategies under another label such as healthy cities or urban regeneration. There was clear commitment to Intersectoral work and some support for joint appointments of directors of public health by health and local authorities. HOTN was seen as failing to address underlying determinants of health, reducing credibility with key partners. Views were divided on whether to adopt a population- or disease-based model. Consistency in central government policies and communication of the strategy were criticised. HOTN was universally perceived as increasing health promotion activities, particularly in the key areas. HOTN received few mentions in corporate contracts and general practice reports. Expenditure on health promotion activities Increased slightly then declined, and HOTN appears to have had only limited influence on resource allocation. Conclusions: Central government, In England, should enable rather than prescribe strategy implementation. It should ensure appropriate structures are in place and that national polices are consistent with the strategy. There is a debate about where the responsibility for health strategy should lie, whether with the NHS or local authorities. The new strategy should address different audiences: local government; the NHS; the voluntary sector; the private sector; and the public. One model is the matrix approach of the European Commission health promotion programme. HOTN failed to engage three groups: the public, primary care, and the private sector. This study has important implications for the monitoring of the new strategy. It needs to be firmly embedded in the work of those who must implement it. It should be incorporated into the NHS performance management framework. The current financial reporting mechanisms preclude monitoring expenditure on a health strategy. Ring-fencing some resources for the new strategy should be considered, if only to give it the high priority it requires. This study, both in terms of the methods used to evaluate the strategy and the lessons learned, could be used by other European countries developing and evaluating their own health strategies.

This is the fourth in a series of seven articles. Changing technology is probably the main force driving the substitution of healthcare resources. This is because new treatments, procedures, and diagnostic techniques allow conditions to be managed in different settings by different staff. Such change is generally incremental, but occasionally new technologies fundamentally change the organisation of care. For example, the development of effective chemotherapy in the 1940s allowed tuberculosis to be managed on an outpatient basis, which led directly to the closure of nearly 30 000 hospital beds and the elimination of an entire class of hospital. Advances in primary prevention might also, in the long term, lead to a reduced need for admission to hospital. Yet such step changes are ultimately outside the hands of clinicians, managers, and policymakers, despite their intimate concern with the organisation, scale, and cost of the hospital sector. The policy debate has tended to focus on what might be described as the “appropriateness gap”—how to provide substitute care for inpatients who do not strictly need to be in hospital because of current technologies. #### Summary points Changes in diagnostic and treatment technologies, rather than policy interventions, are the most potent force leading to the substitution of one form of healthcare service for another. Many inpatient bed days and admissions are deemed inappropriate—but the appropriateness of admission to hospital can tell us nothing about whether patients would be more cost effectively cared for outside hospital. Several services that attempt to be substitutes for hospital care—either by preventing admission or by hastening discharge—have been experimented with. Many apparent substitutes for hospital care seem, in the United Kingdom, to increase overall demand for services, with little impact on overall hospitalisation or costs. Most patients admitted to hospital in the United Kingdom have no alternative but to be admitted: they …