Australian Health Economics Society

Affiliated with iHEA

2017 Conference Abstracts

Thrusday 21st September

Time Paper 1 Paper 2 Paper 3 Paper 4
8:30 - 9:00 Registration
8:45 - 9:00 Welcome Address
9:00 - 10:00 Plenary Session 1: Prof Meredith Rosenthal
“Value-based health care reform: the role of payment and organizational structure”
10:00 - 10:30 Morning Tea
10:30 - 12:10 Parallel Session One
Session 1A:Economic Evaluation 1
Gold Wubishet Windegger Carvalho
Session 1B Health Policy
Creelman Clarke Henshert
Session 1C: Physician Behaviour
Sun Zhang Chen Irving
12:10 - 1:10 Lunch
1:10 - 2:50 Parallel Session Two
Session 2A: Assessing the cost‐effectiveness of genetic screening versus standard practice using microsimulation modelling
West Lymer Tan Cunich
Session 2B: Health and Employment
Maruyama Jackson Byrne Abimanyi‐Ochom
Session 2C: Incorporating Socioeconomic Position in Economic Evaluation of Obesity Prevention Interventions
Tan Hayes Lung Lal
Session 2D Long Presentation Session 1
Zaresani Chan
2:50 - 3:20 Afternoon Tea
3:20 - 5:00 Parallel Session Three
Session 3A Economic Evaluation 2
Watts Campbell Nguyen Mumford
Session 3B Health Care
Cutler Kotz Pulok Wright
Session 3C Health in Middle Income Countries
Maitra Contreras Suarez Hasanah Behera
Session 3D Health Economics
Paarsnis Labeit Cheng Kunz
5:30 - 6:30 AHES AGM
7:00 - late Drinks and Dinner.

Friday 22nd September

Time Paper 1 Paper 2 Paper 3 Paper 4
8:45 - 10:25 Parallel Session Four
Session 4A Stated Preference Studies 1
Olin Angell Howell Fifer
Session 4B Formal and informal health workforce
Shrestha Segal Abbasi‐Shavazi
Session 4C Subjective Health and Wellbeing
Niu Huang Arora Hua
Session 4D Competition in the Australian market for health care services
Scott Mendez Sivey Yang
10:25 - 10:50 Morning Tea
10:50 - 11:40 Parallel Session Five
Session 5A Economic Evaluation 3
Session 5B Quality of Life Measurement
Palmer Comans
Session 5C Cost Effectiveness
Gumbie Tew
Session 5D Predictors of obesity
Ahmed Tam
11:40 - 12:40 Plenary Session 2: Prof Maarten Lindeboom - “Income, Work and Mental Health”
12:40 - 1:40 Lunch
1:40 - 3:20 Parallel Session Six
Session 6A Stated Preference Studies 2
Milte Gu Parkinson Manipis
Session 6B Jaminan Kesehatan Nasional (JKN): Delivering the biggest social health insurance in the world
Soewondo Johar Satrio
Session 6C Financial and nonfinancial incentives for increasing and sustaining rural health workforce
Swami Zhao Bablani Yong
Session 6D Long Presentation Session 2
Nakamura Kong
3:20 - 3:50 Afternoon Tea
3:50 - 4:40 Parallel Session Seven
Session 7A Special Session on the Medical Benefits Schedule Review
Elshaug Van Gool
Session 7B Obesity and Eating Disorder Interventions
Le Nguyen
Session 7C Economic Evaluation 4
Cannon Tran-Duy
Session 7D Out-of-Pocket Health Expenditure 2
Fong Pan

Conference Sponsors

AHES gratefully acknowledges the support of platinum conference sponsors Cochlear and silver conference sponsors Northern Sydney Local Health District.

Inequality and lifetime economic costs of overweight and obesity: a simulation modeling approach
Authors: Diana Sonntag, Marc N. Jarczok, Shehzad Ali

Objective. To quantify the magnitude of lifetime costs of overweight and obesity by socioeconomic status (SES) in young adulthood.

Design and Methods. Using longitudinal data of the Socioeconomic Panel (SOEP), we developed an Obesity Model using Markov modelling technique. We then conducted a systematic review to identify studies reporting cost of overweight and obesity in young adulthood followed by combining the evidence using random effects meta-analysis. SES was measured by a multi-dimensional aggregated index based on level of education, occupational class and income. We then simulated a cohort with different baseline weights at age 18 and followed to death or up to age 80 of their lifetime was carried out in order to analyze health care and societal costs.

Results. Our analysis showed that the majority of overweight and obese young adults with middle and low SES remained in the same BMI category during their adult life, resulting in significant health care and societal costs over the lifetime. Compared to individuals with a high SES during young adulthood, the expected lifetime costs for individuals with low SES during young adulthood were almost doubled (€5,824 million).

Conclusions. Our study showed that SES in young adulthood has a substantial impact on the magnitude of lifetime excess burden of overweight and obesity. This is an important result for public health policies, as our study could form a foundation for proposing to tailor interventions to the specific needs of SES-related sub-groups whilst emphasing the importance of their obesogenic environmental settings.

Why do multi attribute utility instruments produce different utilities: The relative importance of the descriptive systems, scale and 'micro utility' effects.
Authors: Jeff Richardson, Angelo Iezzi, Munir A Khan

Different multi attribute utility (MAU) instruments produce different utilities for the same health state. This is necessarily a result of differences in the descriptive systems and differences in the utility formula which convert item responses to an index of utility. The utility formulae have two effects. First, they impose an implicit scale upon the data and, secondly, they vary utilities in accordance with item parameters and the interaction of the parameters: an amount which is referred to here as the ‘micro utility effect’. The present paper investigates the relative importance of the three components – the descriptive system, scale and micro utility effects – in each of the pairwise comparisons between five multi attribute utility instruments: viz, EQ-5D, SF-6D, HUI 3, 15D and AQoL-8D.

The five MAU instruments were administered to a sample of 8,022 patients and the public in six countries. Three sets of data were produced for each instrument. The first was obtained by applying the published utility formula to obtain ‘utilities’. The second, an unweighted ‘score’, was calculated from item responses. The third was obtained by applying a linear transformation to the scores to obtain ‘values’ which are on the same scale as the corresponding instrument utilities. For each pairwise comparison of instruments, scale effects were determined by the linear relationship between utilities, the effect of the descriptive system by a comparison of scale adjusted values and the ‘micro utility effects’ by the amount which would convert the difference in values to the difference in utilities

Hospital admitted patient expenditure by disease and age: 2004-05 to 2012-13
Authors: Adrian Webster; Rebecca Bennetts; Sadie Law

‘Disease expenditure’ estimates provide insight into the cost and use patterns of health services, and are used for analysing time trends and to make projections of future health expenditure. Both in Australia and internationally, methods for attributing admitted patient expenditure to diseases or conditions have tended to attribute the total cost of a hospital stay to the main diagnosis assigned as occasioning the admission to hospital; this is known as the ‘principal diagnosis’ in Australia and is recorded using the International Classification of Diseases.

 While this method provides valuable broad perspectives on disease expenditure, it underplays the role of co-morbidity and of diseases or conditions that arise during a hospital stay. This particularly affects diseases such as diabetes, which often impact upon the care required but is not usually the principal diagnosis.

To overcome this limitation, the AIHW has developed a method for attributing hospital admitted patient expenditure to all cost-relevant diagnoses. The main barrier to developing this method was the lack of a clear hierarchy of diagnoses in hospital activity data. That is, there is often no clear indication in hospital activity data as to which diagnoses may have had more or less impact on the resources required to care for the patient. The AIHW has used recent work by the Independent Hospital Pricing Authority to help overcome this barrier and to develop a consistent time series spanning from 2004-05 to 2012-13. The result is a data set from which information on disease expenditure can be derived that takes into account co-morbidities and conditions onset following admission. These data also provide insight into hospital admitted patient expenditure by population characteristics such as age, sex and location and how these have changed over time.

Investigating older people and informal carer’s views and preferences for CDC: A Discrete Choice Experiment
Authors: Billingsley Kaambwa; Emily Lancsar, Nikki McCaffrey, Liz Gill, Ian D Cameron, Maria Crotty, Julie Ratcliffe

Consumer directed care (CDC) is currently being embraced within Australia and internationally as a means to promote autonomy and choice for older people receiving community aged care services (CACSs). CDC involves giving CACS recipients (older people and informal carers of older people) control over how CACSs are administered. However, CDC models have largely developed in the absence of evidence on recipients’ views and preferences. We explored CACS recipients’ preferences for a variety of CDC attributes and identified factors that may influence these preferences, and in turn can be used to inform improved design of future CDC models.

Study participants were recipients of CACSs delivered by five Australian providers. Using a discrete choice experiment (DCE) approach, we investigated which of six CDC attributes (choice of service provider(s), budget management, saving unused/unspent funds, choice of support/care worker(s), support-worker flexibility and level of contact with service coordinator) were important to CACS recipients. The DCE data were analysed using firstly, a mixed logit regression model, which accounts for preference heterogeneity, and secondly using the generalised multinomial logit model, which accounts for preference and scale heterogeneity simultaneously and results compared.

Mean ages for 117 study participants were 80 years (87 older people) and 74 years (30 carers). In order of strength of preference, all participants preferred a CDC approach that allowed them to: save unused funds from a CACS package for future use; have support workers that were flexible in terms of changing activities on the CACS care plan and; choose the support workers that provide their day-to-day CACSs.

DCEs are practical and feasible in populations of older people with varying levels of quality of life status and help to assess preferences for elements of potential future CACSs delivery not yet available in policy.

Authors: Anam Bilgrami

The Fairer Private Health Insurance Incentives (FPHII) reforms were introduced in July 2012 and encompassed means-testing of the private health insurance (PHI) rebates, as well as increased rates of the Medicare levy surcharge (MLS) for higher income earners. Past studies in Australia have analysed the impacts of the earlier PHI reforms of the late 1990s and early 2000s and have relied wholly on cross-sectional data to analyse insurance choices in response to policy reforms, which may not be as empirically powerful as following the PHI decisions of the same individuals over time. No studies have, as of yet, empirically analysed the FPHII reforms.

This study examines the impacts of the 2012 FPHII reforms on the probability of holding PHI cover and on potential downgrading of policies. The study analyses longitudinal data from two waves of the Household, Income and Labour Dynamics in Australia (HILDA) survey. The inclusion of PHI variables in the 2009 and 2013 waves (just before and after the FPHII reforms) offers a unique opportunity to analyse the effects of the reforms using longitudinal analysis. HILDA also includes estimates of household PHI premium expenditure in every wave, which allows the opportunity to construct measures of PHI downgrading, an outcome variable which no past studies have looked at.

The availability of longitudinal data permits the construction of a first-difference estimator and difference-in-differences (DID) analysis is undertaken to estimate policy effects. Explanatory variables that affect PHI demand were identified from literature, matched to the HILDA dataset and included in the model. It is assumed that controlling for these variables assists the common trend assumption, required for DID analysis, to hold.

Implications of the estimated policy effects, including for potential government revenue, are discussed.

The impact of regular GP visits on diabetic hospitalisation costs
Authors:David Youens; Kees van Gool; Jane Hall; Rachael Moorin

High quality primary care is associated with better management of diabetes which, in turn, should lead to better health and reduced likelihood of hospitalisation.  The Medicare Enhanced Primary Care (EPC) program (now Chronic Disease Management) was introduced to improve the quality and continuity of primary care provided by GPs to Australians with chronic disease. This program has previously been shown to lead to more regular GP contact in older Australians. The aim of this study is to ascertain whether more regular GP access reduces diabetes hospitalisations.

Whole of population longitudinal study for the period 1990-2004 using linked hospital, mortality, electoral roll and Medicare data. Regularity of GP access was determined through calculating the variance in the number of days between GP visits in each year. Regular GP contact is taken to indicate planned, proactive primary care. Multilevel modelling techniques examined the relationship between regularity of GP access and diabetic hospitalisations in the population at risk of diabetes. Hospital use was characterised both in terms of the number and cost of admissions. Analyses were performed separately for different clinical cohorts of individuals considered to be at risk of diabetes hospitalisation.

Results differed between different clinical cohorts. Regular GP contact may have a protective effect against future hospitalisation, however this appears to be limited to the most severe diabetics. Results also differed in the periods prior to and following the introduction of the EPC program.

Results here did not conclusively demonstrate increased regularity as linked to reduced future hospitalisation costs. Previous work examining time to death or first hospitalisation among different conditions found stronger evidence of a beneficial effect. The concept may be more meaningful for some conditions than others, or may become more meaningful over a longer period. Future research will address these questions.

What would it take for hospital accreditation to be cost-effective? a threshold analysis case study
Authors: Virginia Mumford; Bonny Parkinson; David Greenfield; Johanna Westbrook; Jeffrey Braithwaite

Objectives: Accreditation is designed to improve patient safety and quality of care through assessing whether hospitals have appropriate clinical governance programs in place. However, there is little evidence that accreditation programs are cost-effective in achieving these stated aims. We used threshold analysis to estimate the reduction in two safety and quality indicators (infection rates and inpatient falls) required for accreditation programs to be cost-effective.

Methods: We used published incremental costs of accreditation in Australian hospitals, with hospital acquired Staphylococcus aureus bacteraemia (SAB) rates and inpatient falls as indicators of accreditation. We used published data for length of stay (LoS) and associated costs to determine health related costs, and Quality of Adjusted Life Years (QALYs) to measure patient impact from infections. All costs were adjusted to FY2014-15 using 5% rates. A sensitivity matrix was compiled to include the reported ranges of the component results.

Results: The costs of accreditation in Australian public hospitals were AUD43.96 million in 2014-15FY based on 0.097% of recurrent hospital expenditure (AUD45.32 billion in 2014-15FY). The mid-point sensitivity analysis costs for non-fatal SAB infection costs were AUD28,547 using associated LoS of 12.1 days, daily inpatient costs of AUD2336, and 0.007 QALYs (1QALY=$40,000). Fatal infection costs were AUD477,866 (7.0 QALYs). The cost of an inpatient fall was AUD25,557 using LoS and hospital cost data. Threshold analysis indicated accreditation costs equated to a 1% fall in infection rates and 0.75% decrease in patient falls.

Conclusion: Determining whether accreditation is cost-effective in improving patient safety and quality of care is challenged by linking accreditation programs with outcomes. Our results indicate only a small reduction in two key quality and safety metrics are required for hospital accreditation to be cost-effective

The mind-body connection: Validating subjective reports of poor health against objective physiological dysregulations
Authors: Claryn Kung; David Johnston; Michael Shields

Recurring socioeconomic surveys often include simple subjective wellbeing measures, on which a large body of economic literature relies when studying the determinants of human wellbeing. Despite their importance, little is known about the information contained in these measures. To better understand this concept, several economists have explored the validity of these subjective reports against observables ranging from self-reported lifestyle habits, to physician-prescribed medications, to objective physiological indicators (‘biomarkers’). This paper aims to contribute to this growing literature by assessing whether reports of poor mental health in response to stressful life events (‘shocks’) are replicable using biomarker levels, in terms of deviations that reflect stress-related physiological dysregulations. Guided by the allostatic load framework (bodily ‘wear and tear’ from chronic stress), we select four biomarkers: cortisol, a primary mediator of stress-related dysregulations; and glycosylated hemoglobin, blood pressure, and c-reactive protein, which are metabolic, cardiovascular, and inflammatory parameters, respectively, that are involved in secondary adaptations to chronic stress (or prolonged cortisol secretion).

We employ the National Child Development Study, a prospective birth cohort study that allows us to not only assess raw correlations but also match respondents on their propensity to experience shocks that are likely to affect their mental health. Propensity scores are predicted from extensive mental health history and labour market history variables, alongside pre-shock demographic characteristics. Conditional on past mental health and economic background, economic shocks predict poorer self-reported health as well as depressive and anxiety symptoms, whereas social shocks only predict the latter. Both types of shocks also predict allostatic biomarker levels in expected directions, but there is no clear correspondence between reportedly poor mental health and associated physiological dysregulations. Although caution is required when interpreting these results, they suggest that subjective reports of health do not necessarily reflect objective physiological dysregulations.

Refugee populations and Emergency Department use in the Adelaide metropolitan area: Examining outcomes and costs using linked, administrative data
Authors: David Banham; Anh-Minh Thi Nguyen; Kay Anastassiadis;

Potentially Preventable Hospitalisations (PPHs) are an indicator of primary health care availability and effectiveness. While PPHs often focus on inpatient stays they are also relevant to emergency department (ED) visits. Specific population groups are vulnerable to higher PPHs. Anecdotally, refugee and asylum seekers (RAS) are one such group. Systematic disparities in hospital contacts have implications for people’s health outcomes and system costs and thus require scrutiny.
This presentation collates empiric evidence of RAS contact with ED services. In particular, the presentation:
• Describes changes in the underlying RAS population and volume of ED contacts, including PPHs;
• Enumerates individuals experiencing these contacts and the frequency of their contact; and
• Estimates the costs associated with any excess presentations.

Countries of birth associated with humanitarian arrivals provide RAS population numbers. Individually linked public hospital records in the Adelaide metropolitan area for 2005-06 to 2010-11 are categorised using Australian Institute of Health and Welfare definitions for PPHs and GP-type presentations. The Pricing Framework for Australian Public Hospital Services 2014-15 provides cost weights. The main outcome measures used are proportions and crude rates of PPHs and costs by geographic region.

Preliminary analyses indicate a doubling of RAS contribution to total ED activity over time. This is not associated with substantive change in ED visit rates per capita. However, results do suggest visiting individuals are less likely to have one presentation and increasingly likely to have three or more ED visits annually.

Compared with the wider community, RAS within Greater Adelaide appear to have poorer utilisation of effective primary care resulting in PPHs to EDs. This indicates an emerging issue of health inequality and cost pressure. The implications of these findings for commissioning services that meet population need in effective, efficient and equitable ways is discussed.

Cost-utility analyses of drug therapies in breast cancer: a systematic review and critical appraisal of health-state utility values
Authors: Sopany Saing; Georg Kemmler; Eva Maria Gamper; Franck Daval; Bernard Holzner; Xavier Pivot; Rosalie Viney; Virginie Nerich

Purpose: Economic evaluation has become an essential part of decision making. In conditions such as breast cancer (BC) with quality of life impacts, wide range of treatment options and associated adverse events, cost-utility analyses (CUA) should be preferred to cost-effectiveness analyses. However, little attention has been given to the quality of BC related CUA. A systematic review and assessment of quality of published CUA related to drug therapies and testing for BC was performed. A critical appraisal of health-state utility values (HSUV) used in the BC related CUA was also performed. Methods: The systematic literature search was conducted in PubMed, Medline/Embase and Cochrane to identify published CUA between 2000 and 2014. The quality of CUA was assessed by two independent reviewers using the Drummond et al. checklist, where a score ≥ 7 was synonymous with ‘high quality’. Predictors of quality were also determined. A checklist was developed to review the selection, the elicitation and the use of HSUV. Results: The review identified 140 CUA, and revealed differences in the measurement of cost and effectiveness, more specifically health-state utility values. Half of the CUA (n = 74) had a score ≥ 7 (range: 3-10). Overall, only one third of studies adequately valued costs and consequences credibly. Only a ‘partial’ sensitivity analysis was performed in three-quarters of the cases. A predictor of higher quality CUA included articles presenting both incremental cost-utility ratio and incremental cost effectiveness ratio (p=0.02). A critical appraisal of the HSUV used was analysed. Conclusions: Over the last 5 years there has been a tendency towards an improvement in the quality of published studies. However, adherence to recommendations as part of the ISPOR Guidelines are needed to improve the quality of published CUA including sensitivity analysis and the valuation of HSUV.

Cancer survivors find it difficult to think hypothetically about their future care in a discrete choice experiment - results of a think aloud study
Authors: Alison Pearce; Linda Sharp; Pamela Gallagher; Aileen Timmons; Verity Watson;

Purpose: To use qualitative methods to investigate why cancer survivors prefer the status quo, and don’t trade-off between attributes, in a discrete choice experiment (DCE) of cancer follow-up care in Ireland.

Methods: We conducted ‘think aloud’ interviews with 17 prostate and colon cancer survivors who completed a rigorously developed DCE of preferences for cancer follow-up services. The DCE contained 8 choice sets each with 8 attributes, including cost. Within the interviews we tested: a cheap talk script, forced and opt-out choice sets, and debriefing questions for comprehension, engagement, and attribute non-attendance. Our analysis used an iterative framework approach to assess decision making both within and across participants.

Results: Participants found the DCE cognitively challenging, and many completed it in a way that was inconsistent with utility maximising assumptions. We identified three respondent types within our sample. Group A compared the packages and made trade-offs, but their choices were dominated by one or two attributes and status quo bias. Group B had difficulty imagining that they might have a treatment choice, and therefore thought they should report the facts of their current follow-up. Group C could not complete the choice task, skipping choice sets or selecting multiple alternatives per choice. The cost attribute was almost universally ignored, despite using a cheap talk script. Those who found the choice task unclear (Groups B & C) also found the debriefing questions unclear.

Conclusion: Many cancer survivors found it difficult to think hypothetically about their future care. The debriefing questions could not distinguish fact based responses from preference based responses, suggesting the need to revise DCE debriefing question. This study highlights the vital importance of pre-testing DCE survey instruments prior to implementation.

Talking about contraception: What doctors decide to discuss with women
Authors: Denzil G. Fiebig; Rosalie Viney; Stephanie Knox; Marion Haas; Deborah Street; Edith Weisberg; Deborah Bateson
Can looks be deceiving? The influence of appearance on teacher assessments
Authors: Nicole Black; Sonja Kassenboehmer

There are some groups of children who tend to perform worse academically than their peers even after controlling for differences in demographic and family socioeconomic characteristics. It is possible that achievement gaps may be due, in part, to teachers over-assessing or under-assessing students’ performance based on certain identifying characteristics. This study examines whether teachers systematically assess students differently based on their weight, height, gender and ethnicity, after controlling for their school test scores, cognitive ability scores and other characteristics of the child, family, teacher and school.  Using data from the Longitudinal Study of Australian Children that is linked to anonymous teacher assessments and objective national test scores (NAPLAN), our results suggest that teacher assessments do vary by the child’s ‘appearance’. For numeracy, heavier or obese children are rated less favourably by their teachers, while boys and taller children are rated more favourably, given their objective performance measures. These results cannot be explained by classroom behaviours or socio-emotional skills. The under-assessment of obese children may perpetuate the psychosocial challenges that obese children face. We further show that being under-assessed in maths is likely to have negative consequences for the child’s future academic performance.

The use of multi-attribute utility instruments in paediatric populations
Authors: Gang Chen; Julie Ratcliffe

The measurement and valuation of health forms a major component of economic evaluation in health care and is a major issue in health services research. Health related quality of life (HRQoL) is a multidimensional construct that measures the impact of health or disease on physical and psychosocial functioning. Researchers in health economics and other disciplines are increasingly recognising the importance of the measurement and valuation of HRQoL in both children and adolescents. Presently there are eight multi-attribute utility (MAU) instruments available internationally which have been developed for application in child and/or adolescent samples: the 16D, the 17D, the Health Utilities Index Mark 2 (HUI2), the HUI3, the Assessment of Quality of Life 6-Dimension (AQoL-6D), the Child Health Utility 9D (CHU9D), the European Quality of Life 5 Dimension Youth version (EQ-5D-Y), and the Adolescent Health Utility Measure (AHUM). The paper critically reviewed the development and application of the above eight MAU instruments, discussed the specific challenges of health utility measurement in children/adolescents, compared the pros and cons of the different instruments, and provided some guidance for use of the instruments and areas for further research and instrument development.

Improving the quality of decision making on health interventions: incorporating the long-term economic impacts of informal (unpaid) care
Authors: Deborah Schofield; Rupendra Shrestha; Michelle Cunich; Megan Passey; Emily Callander; Simon Kelly; Robert Tanton; Lennert Veerman; Theo Vos.

Introduction: Currently cost-effectiveness analyses of health interventions significantly underestimate the benefits of interventions, because no methodology exists for accurately incorporating the long-term society-wide productivity costs of informal care.

Aim: To describe a static microsimulation model, called Care&WorkMOD, which will be built to simulate both the current economic costs of informal caregiving in Australia and projecting future costs to 2030.
Methods: Care&WorkMOD will be used to generate snapshots of the prevalence of chronic diseases associated with people leaving the labour force to take on caring responsibilities, demographic information, and economic impacts of informal care based on Australians aged 21-64 years in 2010 every five years from 2010 to 2030. Care&WorkMOD will be built using three databases: i) the base population – i.e. individuals aged 21-64 years with information on their labour force participation, carer status and chronic conditions of self and care recipient from the Australian Bureau of Statistic’s Survey of Disability, Ageing and Caring (SDAC) 2003 and 2009; ii) output datasets from the National Centre for Social and Economic Modelling (NATSEM’s) Australian Population and Policy Simulation Model (APPSIM), which consists of financial information on Australians aged 21-64 years for the years of interest; and iii) data on trends in disease prevalence. These are discussed in the paper.

Conclusions: Microsimulation modelling is a new approach to projecting the costs of informal care for Australia up to 2030; these include changes in labour force participation of carers, personal income, welfare payments, personal savings, personal wealth and superannuation, taxes and national impacts such as reductions in GD related to reduced labour force participation due to caring responsibilities.

Health related quality of life in mothers of children with behaviour problems: a population-based study
Authors: Ha N.D Le; Alisha Gulenc; Lisa Gold; Anna Sakardi; Obioha C Ukoumunne; Jordana Bayer; Melissa Wake; Hariet Hiscock

Background: Child behaviour problems are associated with poor maternal mental health. However, little is known about how maternal health related quality of life (HRQoL) may be affected by child behaviour problems. The aim of the study are: (1) to examine the relationship between mother’s HRQoL and child behavior problems at age 2 years and (2) to investigate whether the relationship between maternal HRQoL and child behaviour problems is independent of maternal mental health.

Design: Cross-sectional survey nested within a population-level, cluster randomised trial (2010–2014) which aims to prevent early child behaviour problems.

Participants: 1160 mothers of eight month old children attending the universal Maternal and Child Health system, in nine Local Government Areas in the state of Victoria, Australia.
Measures: HRQoL was measured using the Assessment of Quality of Life (AQoL6D) and child behaviour was measured using the Child Behavior Checklist (CBCL/1.5-5 years). Maternal mental health was measured using the Depression Anxiety Stress Scale (DASS).

Results: Health related quality of life was lower for mothers with children that had borderline/clinical problems compared to those with children without problems (mean difference -0.14, 95% CI: -0.16 to -0.12 to, p

Cost-effectiveness of intensive chronic condition management for Indigenous people with poorly controlled type 2 diabetes (T2D) by Indigenous Health Workers (IHWs) in remote communities.
Authors: Ha Nguyen, Leonie Segal, Barbara Schmidt, Robyn McDermott

Background: Indigenous Australians experience a disproportionally high burden of diabetes. The “Getting Better at Chronic Care Project” provided intensive chronic condition management for Indigenous adults with poorly controlled T2DM by IHWs in remote Queensland. This paper reports on the implementation costs and cost-effectiveness of the intervention.

Method: The design was a cluster-randomized-controlled-trial with intervention (N=100) and usual care (N=113) groups. Participants were Indigenous adults with poorly controlled T2DM (HbA1c ≥ 8.5%) plus at least one of: chronic obstructive pulmonary disease, coronary heart disease, chronic kidney disease or hypertension. The primary outcome was differential change in HbA1c at 18 months. There were a number secondary outcomes including hospitalisations and use of Medicare services (obtained from administrative data collections) and quality of life measured by the AQoL 4D. Costs of the intervention were derived from project records and covered the costs of the IHWs delivering the service, their training and clinical and operational support from the project team.

Results: The total cost of the project was $2.089 million of which $1.010 million was attributed to delivery of the intervention (the balance being for evaluation related costs). The cost of service delivery was equivalent to about $10,100/per person or an average annual cost of nearly $6,750/person. A preliminary analyses of the outcomes at 18 months, found a non-significantly greater reduction in HbA1c than the control of 0.53% (0.84% vs. 0.31%, p-value=0.12). In terms of hospitalisation rate and quality of life, there were no statistically significantly differential changes in either the intervention and control groups. The intervention thus costs $10,000/person, for a mean 0.53% additional reduction in HbA1c level.

Conclusion: The intervention provided community-based extra support for poorly controlled T2D patients. The impact on HbA1c levels was modest at best and disappointing given the high level of funding. The reasons for the poor result may include the complexity of the patient population; reflected in very high HbA1c levels (mean 10.7% at base line). In addition, the level of implementation was compromised by challenges of recruitment, retention and absenteeism of IHWs. Future interventions may need to look at intervening earlier in disease stage and explore mechanisms to better retain IHWs.

The economics of a GP co-payment – who would pay the price?
Authors: Ian McRae; James Butler
Implications of misclassification errors in empirical studies of adolescent smoking behaviours
Authors: Ijeoma Edoka

Misclassification errors in a dependent variable introduce a downward bias to covariate effects in a binary choice model. Misreporting of smoking behaviours by adolescents has been widely documented; however, the consequences of misclassification errors in empirical studies of adolescent smoking participation have received little attention. This study uses the Health Survey for England (HSE) to investigate the extent and implications of misclassification errors in self-reported smoking behaviours of adolescents aged 11-15 years. Possible solutions to correcting misclassification errors are explored using the modified maximum likelihood estimator (MLE) approach. The HSE contains both a self-reported smoking component and an objective measure of smoking obtained from saliva cotinine assays. Saliva cotinine concentration ≥ 12ng/ml is considered the ‘true’ indicator of adolescent smoking participation against which self-reported smoking participation is compared. The results suggest that smoking is misreported in this age group, resulting in a downwards bias of coefficients and marginal effects in the self-reported smoking participation model. The modified MLE performs moderately well in correcting misclassification when the misclassification probabilities are treated as fixed known parameters, but not as expected when misclassification probabilities are treated as unknown estimable parameters.

Morbidity interactions and the cost of healthcare: an analysis of a large-sample administrative dataset of primary care, hospital pharmaceutical and total healthcare costs
Authors: Thomas Longden; Chun Yee Wong; Phil Haywood; Jane Hall; Kees van Gool

While the management of individual diseases is something that healthcare systems have been designed to deal with, an increase in the occurrence of co-existing chronic disease has become a challenge for the management of healthcare in Australia and abroad. A related concern is that an inability to efficiently treat cases of multimorbidity has led to increased costs of healthcare provision. In this study, we used the survey data from the 45 and Up Study, which covers more than 267,000 people aged 45 and up in New South Wales (NSW), representing around 10% of the total NSW population in the same age group. The survey data is linked to several administrative health datasets, including the data from the Medical Benefits Schedule (MBS), the Pharmaceutical Benefits Schedule (PBS), the NSW Admitted Patient Data Collection (APDC) and the Emergency Department Data Collection (EDDC), that provide rich detail on an individual’s utilisation of primary care, hospitalisations and pharmaceutical prescriptions. With the utilisation of the linked dataset, we investigate whether there are specific combinations of morbidities that influence healthcare costs. Using classification and regression tree (CART) analysis, this paper identifies the key interactions of morbidities that drive primary care, hospital, pharmaceutical and total healthcare costs. The performance of models using morbidity-based interaction variables is also assessed using a range of distributional regression approaches.

Estimation of Transition Probabilities of Multiple Sclerosis Progression: Evidence from Australia
Authors: Hasnat Ahmad; Otahal P, Ingrid van der Mei; Bruce Taylor; Andrew J Palmer

Background: The probabilities of progression of disability due to multiple sclerosis (MS) have not previously been estimated in Australia.

Objectives: To estimate the probabilities of MS progression between different levels of disease severities in Australian people with MS.

Methods: Using data from Auslong and TasMSL MS epidemiological databases, annual transition probabilities were estimated between classes of disease severity, classified as mild (Expanded Disability Status Scale[EDSS] levels 0-3.5), moderate (EDSS levels 4-6) and severe (EDSS levels 6.5-9.5). Hazard ratios were estimated for sex, age (>=50 years, and =10 years, and =50 years, and longer disease duration (>=10 years) had higher risks of progression to more severe disability states.

Conclusions: For the first time, we have estimated the transition probabilities of progression in Australian people with MS. The transition probabilities we have estimated will serve as an important ingredient to future health economic evaluations of MS in Australia. Future studies in the field are recommended to consider MS progression consequences of other important covariates, particularly relapse rates, disease modifying therapies, genetic differences, and environmental exposures.

A multi-level analysis of the role of academic school quality on academic outcomes for students with language difficulties.
Authors: Paula Cronin, Rebecca Reeve, Stephen Goodall, Rosalie Viney, Tricia McCabe

The relationship between individual language difficulties and academic outcomes is well established and current research confirms that children who are language impaired achieve lower academic grades, complete fewer years of formal education and are more likely to be in less skilled employment. While there is also a considerable evidence base that shows that the quality of schools matter with respect to academic outcomes, little is known as to whether academically higher quality schools contribute to educational outcomes for this sub-group of children. This aim of this paper is to explore whether students with language difficulties benefit to a greater or lesser extent from attending high-quality academic schools when compared with their language typical peers.

This paper uses data from 4725 students in the Kindergarten (K) cohort of the Longitudinal Study of Australian Children (LSAC) linked to the National Assessment Program- Literacy and Numeracy (NAPLAN) and the Australian Curriculum, Assessment and Reporting Authority (ACARA) , which provides a rich set of individual and school level measures. The LSAC tracks a nationally representative sample of 4-5 years olds over a period of 10 years to capture their transitions from pre-school to formal schooling and high school. The analysis uses multilevel linear modelling and the data was analysed in two levels: student and school. We model attrition and deal with possible selection bias using propensity scores.

The results indicate that academic school quality has a considerable differential effect on school academic achievement for children with language difficulties. Although individual’s characteristics are the main drivers of success, school attributes account for approximately 15% of the variation in literacy and numeracy scores. Notably the impact is greatest for those students with the most severe language difficulties and those students who are diagnosed with language difficulties after 8years old.

Preferences in perinatal mental health: a discrete choice experiment
Authors: Jemimah Ride; Emily Lancsar

As discrete choice experiments (DCEs) are increasingly used in health research, so too has scrutiny increased of the underlying assumptions upon which the theory is based. Random utility theory assumes that consumers consider all relevant information when making purchasing decisions and that they maximise their utility gain in a ‘rational’ and ‘consistent’ way. Whilst there is increasing evidence that this assumption does not hold in many situations, especially for complex decisions relating to health and health care, little is known about the extent of any deviation and some of the key drivers. Using eye-tracking technology, which captures the number of times and the duration that a participant looks at any part of a computer screen during the completion of a DCE survey, we can analyse what has become known in the DCE literature as ‘attribute non-attendance’ (ANA). ANA can be directly measured in this analysis when no fixations have been recorded for a particular attribute and thus, the information contained within that attribute cannot have been considered. This approach adds to the previous literature which has relied on deduction and inference to measure ANA in DCEs. Using this approach we analyse the effect of choice set complexity and respondent characteristics on the likelihood of ANA using fixed and random effects models to account for repeated choice set completion. We find that complexity is strongly related to ANA as well as some evidence of heterogeneity in decision making processes. We conclude that this approach provides direct evidence that increased complexity in DCE surveys are related to ANA.

Preferences for Scanning Technologies to Diagnose Focal Liver Lesions Elicited via a Discrete Choice Experiment
Authors: Jennifer A Whitty; Alexandra Filby; Adam B Smith; Louise M Carr

Objective: This study aimed to investigate the preferences of an “at risk” population for the characteristics of scanning modalities used in diagnosing focal liver lesions.

Methods: A discrete choice experiment was administered to 504 adults in the UK, recruited via an online survey panel. Age and gender reflected the demographics of patients diagnosed with cirrhosis and liver cancer. Respondents made repeated choices between two hypothetical scans, described according to waiting time for scan and results, procedure type, the chance of minor side effects, and whether further scanning procedures were likely to be required. Choice data were analysed using mixed logit models.

Results: Respondents preferred a shorter waiting time for the scan and results, the procedure to be undertaken with a handheld scanner on a couch instead of within a body scanner, no side effects, and no follow up scans (p≤0.01). The average respondent was willing to wait almost an additional 2 weeks to have the scan if it resulted in avoiding side effects, approximately 1.5 weeks to avoid further procedures or to be likely to be told the results immediately, and almost 1 week to have the scan performed on a couch with a handheld scanner. Substantial preference heterogeneity was observed around desirable imaging characteristics.

Conclusions: On average, the general population sub group most likely to require imaging to characterise focal liver lesions in the UK would prefer contrast enhanced ultrasound over magnetic resonance imaging or computed tomography. Insights into the consumer perspective around the differential characteristics of imaging modalities have the potential to be used to help guide recommendations around the use of these technologies.

Financial support: Financial support for this study was provided to York Health Economics Consortium, UK via a contract with the National Institute for Health and Care Excellence (NICE).

The Effects of Socio-Economic and Risk Factors on Cardiovascular and Circulatory Diseases: With Corrections for Co-Morbidity, Endogeneity and Selection Biases
Authors: Jinjing Li; Yohannes Kinfu

The increasing burden of cardiovascular diseases (CVDs) and the search for ways and means to ameliorate their impact have long generated interest in identifying the factors associated with the disease. Traditionally, two approaches dominated the scene: those based on follow up studies (FuS) in a controlled (often clinical) setting and those that used cross-sectional surveys (CSS). However, both approaches have their own shortcomings. FuS are expensive; they focus on a single health condition and have limited generalizability beyond the study population. On the other hand, CSS, while being less costly and have often larger samples, they lack information on disease progression and timing of explanatory variables. In this paper, we exploit the panel component from the Australian Household, Income and Labour Dynamics survey (HILDA) and re-examine the effects of explanatory variables on CVD. The data set, which has a large sample, and contains information on timing of events that mimics a large-scale clinical experiment and on multiple health conditions allow us to control for co-morbidity, endogeneity and selection biases. The study confirms many existing findings on risk factors such as smoking and physical exercises, but also suggests the importance of SES may have been over-estimated in cross-sectional models.

Measuring Social Preferences for Treating the Permanently Disabled and Chronically Ill: Eliminating a Framing Effect
Authors: John McKie; Jeff Richardson; Jan Abel Olsen

Evidence suggests that the value members of the public place on saving the lives of patients with a disability or chronic illness differs depending on whether the patients were previously disabled or ill (the pre-existing scenario) or will be left so after treatment (the onset scenario). This is so even when the future QALYs (quality-adjusted life years) are identical. Further, the value people place on saving the lives of patients in both cases can differ significantly depending on the order in which subjects are presented with the scenarios. For example, the value subjects place on saving the life of a healthy patient who will left paraplegic after treatment may differ ten-fold depending on whether they have previously been asked about life-saving treatments for pre-existing paraplegics. If social preferences are to be taken into account in economic evaluations this presents a problem. Which set of preferences should count? Using data obtained from a series of in-depth, small-group discussions with members of the public we explain how we eliminated the order effect, report the distributional preferences of participants in its absence, and present the reasons for participant’s choices.

Preference-based outcomes: representative or age-matched general population values?
Authors: J Karnon; JE Brazier; RM Ara; BA van Hout

Assessing hospital performance using hospital administrative data
Chair: Tony Scott, University of Melbourne
Session Organiser: Jongsay Yong
Authors: Ying Chen; Terence Cheng; Choon Cheng; Tony Scott; Vijaya Sundararajan; Jongsay Yong

Health care costs and quality of care are two major concerns of all governments. In Australia, hospital care accounts for almost 40% of total health care expenditure, around 3% of GDP, and expenditure on public hospitals grows at 5-6% per year in real terms. Although expenditure is growing, hospital performance does not appear to keep pace. There are continuing concerns about the performance of public hospitals across Australia. These concerns range from quality and safety, waiting times, financial deficits, cost-shifting, workforce shortages, the role of technology, and the interaction with the private hospital and aged care sectors. These issues can have significant impacts on the quality of care and health outcomes of patients. This session consists of four presentations on using hospital administrative data to shed light on hospital performance such as quality of care and hospital efficiency, and the key drivers that are correlated with hospital performance.

Together these presentations address a number of important issues pertaining to hospital performance; they also highlight how hospital administrative data could be used to address these and other related issues.

Presentation 1: Linkage of the Victorian hospital administrative datasets and its value for research and policy development

Presenter Ying Chen, Victorian Department of Health

This presentation provides an overview of linked hospital administrative datasets available for researchers from the Victorian Department of Health. It highlights the enhanced value that data linkage adds to research using hospital administrative data, leading to greater possibilities in answering a broader range of research questions. The advantages and limitations of the Victorian linked hospital administrative data are also discussed and the current barriers and challenges around data linkages are explored.

The Victorian Data Linkages Unit (VDL) was established in 2009 with combined funding from the Australian and Victorian Governments as the Victorian node in the national Population Health Research Network (PHRN), to build a data linkage infrastructure capable of securely managing health information for health and medical research.

The Victorian Data Linkage Map contains enduring links between key hospital datasets and mortality datasets. In addition, VDL has responded to the needs of the researchers as well as government programs in undertaking the project specific linkages linking key hospital datasets to other health datasets. VDL has developed sophisticated data linkage methods and strategies by using privacy preserving methods to link together records pertaining to the same individual within or across different administrative datasets. De-identification and encryption rules are applied to remove identifying information about patients, service providers and service dates. The hospital datasets are enriched with socio-economic-geospatial indicators at small area level.

The benefits of hospital administrative data linkage are recognised as a resource for public good. However, there are also constraints that limit linkage of hospital administrative data to other datasets for research purposes. The barriers include current legislative framework governing collection and disclosure of information, insufficient common identifiers across data collections, quality of data collections, and different perspectives of data custodians versus researchers.

Presentation 2: Tracking hospital quality using Victorian hospital administrative data

Presenter Choon Cheng, Victorian Department of Health

This paper measures risk-adjusted mortality and readmission rates of Victorian hospitals using hospital admission data for an 11-year period from 2001/02 to 2011/12. For the purpose of risk adjustment, a standard logistic model is developed to take into account differences in patient characteristics including age, gender, principal diagnosis, admission type, comorbidity and care type. In total more than 23 million admission episodes occurring in 310 hospitals are used in the analysis, which provides an overview of the quality of hospital care in Victoria. Preliminary findings suggest that quality of care has been improving over time, but small public hospitals consistently lag behind other hospital types. Further analyses suggest that there exist considerable degrees of heterogeneity among small public hospitals. Considerable degrees of heterogeneity also exist among private hospitals, although private hospitals generally perform better than public hospitals in risk adjusted mortality and readmissions.

Presentation 3: Understanding hospital productivity using Victorian hospital administrative data

Presenter Jongsay Yong, University of Melbourne

Abstract This paper investigates the productivity of Victorian public hospitals using hospital admission data for the five-year period 2007/08 to 2011/12. We construct measures of total factor productivity using aggregate output and input indices. Aggregate output index is constructed by enumerating all in-patient activities of a hospital and are aggregated using diagnostic related group costs as weights. Aggregate input is constructed by adding total dollar costs of labour, capital, and materials. Total factor productivity (TFP) is computed as the ratio of aggregate output index to aggregate input index. Preliminary results suggest that, without taking into account changes in quality, hospital TFP did not register any material changes during the five-year period. Closer inspection further reveals that tertiary hospitals generally perform best in productivity among all hospitals, and small hospitals tend to exhibit greater degrees of variations in TFP growth than other hospitals.

Presentation 4: An investigation of cream-skimming using hospital administrative data

Presenter Terence Cheng, University of Melbourne

In this talk Terence Cheng will present the latest developments from a research project where we investigate the presence of cream-skimming behaviour using the novel approach of analysing hospital transfers. Using Victorian hospital administrative data we examine if patients transferred between public and private hospitals differ systematically in the severity and complexity of their medical conditions. We find that patients with higher disease severity are more likely to be transferred from private to public hospitals whereas the opposite is true for patients transferred to private hospitals. We also find that patients transferred from private to public hospitals stayed longer and cost more than private-to-private transfer patients, after controlling for patients’ observed health conditions and personal characteristics. Our findings are consistent with cream skimming behaviour by private hospitals.

Retrospective economic evaluation of childhood pneumococcal vaccination in Australia
Authors: Anthony T. Newall; Josephine F. Reyes; Peter McIntyre; Robert Menzies; Philippe Beutels; James G. Wood

Cost-effectiveness analyses are primarily used to provide evidence for policy and funding decisions before health interventions are implemented. Retrospective economic evaluations have received less attention in the literature. By making use of data collected post-implementation, retrospective cost-effectiveness analyses of vaccine programs may substantially reduce uncertainty and provide a better assessment of the value for money achieved. As a case study, we conducted a retrospective economic evaluation to assess the cost-effectiveness of the nationally funded 7-valent pneumococcal conjugate vaccine (PCV7) program in Australia. This is the first study specifically designed to evaluate the cost-effectiveness of an existing vaccine program in Australia. We designed a static, deterministic model that describes transitions between health states for a population over time. We investigated health-related outcomes on which PCV7 may have had an impact, primarily invasive and non-invasive pneumococcal disease. We applied a healthcare perspective and included costs for the vaccination program as well as healthcare utilisation. Quality-of-life utility weight estimates were attached to the different health states in the model. The primary outcome calculated was an incremental cost per Quality Adjusted Life Year (QALY) gained. We conducted one-way and probabilistic sensitivity analysis, and examined a number of different scenarios. In the scenario where observed declines in all health outcomes were attributed to PCV7, the ICER was below A$50,000 per QALY gained. However, in scenarios where only declines with more robust evidence for attribution to the program were included, the cost-effectiveness was less clear-cut. We discuss how our results compare to previous pre-implementation cost-effectiveness studies on PCV7 in Australia, and how methodological choices impact on cost-effectiveness results. Retrospective cost-effectiveness analysis can provide important insight in our understanding of the value for money achieved by vaccination efforts.

Cost of hospital and health service utilisation of very pre-term infants from the ProPrems Neuro study
Authors: Kah-Ling Sia; Lisa Gold; Sue Jacobs; Jeanie Cheong; Gillian Opie; Suzanne M. Garland; Leah Hickey; Rosemarie Boland; Chelsea Webster for the ProPrems Study Group

Patient contrbutions in Solomon Islands and Papua New Guinea: Whether and how to eradicate them
Authors: Katherine Gilbert; Duncan Mortimer; Nicole Au; Rohan Sweeney; Jean Spinks; Ajay Mahal; Wayne Irava; Paula Lorgelly

The Solomon Islands Ministry of Health and Medical Services (MHMS) delivers health care to over 500,000 people in predominantly rural areas across 10 provinces, including numerous remote islands. It has a budget of SBD 552 million (AUD 81 million), which is sourced from annual appropriations from national revenue and from development partners as part of the Health Sector Support Program (HSSP).

The MHMS is committed to providing free universal access to health services; and the current National Health Act restricts the collection of fees at health facilities to hospitals. A recent Patient Exit Survey undertaken in Solomon Islands found that despite this explicit restriction patient contributions are common across all facility levels for consultations and medical record books, excluding the National Referral Hospital in Honiara.

The accompanying Health Facilities Costing Survey found that revenue collected from patient contributions are the only sources of revenue managed by facilities. Health workers reported that these contributions are used to cover gaps in the salaries and supplies provided by the national and provincial health administrations.

A detailed analysis of who makes patient contributions suggests that the poor and women pay such fees more often, but they do not appear to be a barrier to access and are waived for those who cannot afford to pay. Evidence from a recent study in PNG (Wiltshire and Mako 2014) shows a similar context. While eradicating such fees is consistent with the MHMS policy and promotes the WHOs universal health care policy, it presents administrative challenges for the MHMS and has additional cost implications in getting cash to health facilities, and supporting them to manage it appropriately.

This paper will explore the options available to the MHMS and other low and middle income countries who wish to abolish user fees.

Primary care in Australia: towards better quality and value for money
Chair: Denzil Fiebig; presenting authors: Ian McRae; Rachael Moorin; Anthony Scott; Chunzhou Mu

Primary care in Australia: towards better quality and value for money

Chair: Professor Denzil Fiebig

Primary care has been the subject of substantial policy changes in recent times. Proposed government reforms have focused on changes to the funding of GP services as well as on organsisational aspects, including the establishment of regionally-based primary health networks (PHN). This organised session will examine some of the key policy challenges, covering issues relating to funding, efficiency, quality and equity in the field of primary care. Four papers from leading researchers in the fields of health economics and policy will be presented in this session:

The economics of a GP co-payment

, Dr Ian McRae*, Australian National University
The Australian Government’s proposal for a $7 GP co-payment, if implemented, will impact on patients’ out-of-pocket costs, their attendance at surgeries and on GP earnings. We explore both estimated supply and demand responses for the overall GP market and possible responses in different market segments.

Capturing regularity of MBS funded primary care services in WA: Evaluation of its relationship to frequency and cost

, Associate Professor Rachael Moorin*, Curtin University
The rapidly ageing population, high prevalence of chronic illnesses, and ever increasing expectations in service delivery are placing the Australian health care system under increasing pressure. Approaches to reduce this unsustainable demand include policies to improve the regularity and quality of healthcare provided by GPs. This presentation will showcase methodology developed to evaluate service regularity as distinct from frequency of GP visits using longitudinal whole-of-population linked individual level Medicare and hospitalisation data.

What explain the use of GPs?

Ms Chunzhou Mu*, Professor Jane Hall CHERE, University of Technology, Sydney
Geographic variation in GP use is a persistent finding across Australia. Some of this variation may be warranted, reflecting differences in, for example, population health status. However, variation may also be indicative of health care inefficiency and inequity. This paper examines the amount of geographic variation in GP use, and the factors that influence that variation. Results suggest that health care needs, age, obesity, lower socio-economic status are significant drivers of health care use. The availability of more GPs is also associated with higher GP use but the supply of more specialists reduces the use of GPs. A better understanding of the sources of the geographic variation can inform policy interventions to prioritise resource allocation and improve health care delivery efficiency.

Do financial incentives influence GPs’ decisions to provide after hours care? A discrete choice labour supply model.

Barbara Broadway, Guyonne Kalb, Anthony Scott*, Jinhu Li, Melbourne Institute of Applied Economic and Social Research, The University of Melbourne
The aim of this paper is to examine the effects of changes in financial incentives on whether GPs provide after hours care, using data from the first wave of the MABEL survey. A discrete choice labour supply model is used where decisions on total hours worked are combined with decisions on whether or not to provide after hours care. Sixty percent of men and 41% of women GPs do some after hours work. Preliminary results show that if earnings from working after hours increase by 1%, then the probability of undertaking after hours work increases by around 0.1%. Women with children are less likely to increase their after hours workload in response to a wage increase, compared to women with no children and men. Overall, the results suggest that GPs are not very responsive to increases in earnings for after hours work. Family factors and whether the GP is self-employed seem to play a larger role.

Following the presentations, there will be an opportunity for discussion among participants and the authors.

* presenting author

Health, austerity and economic crisis: assessing the short-term impact in OECD countries
Authors: Kees van Gool; Mark Pearson

The economic crisis that started in 2008 has had a profound impact on the lives of citizens. Millions of people lost their job, saw their life-savings disappear and experienced prolonged financial hardship. The economic crisis has also led a number of OECD governments to introduce austerity measures to reduce public deficits. The combined effects of economic crisis, austerity and reforms have led many OECD health systems into unchartered territory.

This paper looks at the impact of economic crisis on health and health care. It summarises findings from the published literature on the effects of economic crisis that took place over recent decades. This paper also analyses the empirical relationship between unemployment and health care use, quality and health outcomes, using data from OECD Health Statistics. In doing so, it investigates whether the effects of unemployment on health outcomes have been extenuated by austerity measures.

Results show that economic downturns are associated with adverse outcomes for some, but certainly not all, health indicators. During times of economic crises, mental health deteriorates and the prevalence of communicable diseases appears to rise, but at the same time there are fewer deaths from transport accidents. There is less consistent evidence on the relationship between economic conditions and overall health outcomes such as mortality and health care quality but there is evidence that higher rates of unemployment are strongly linked to lower health care use. Austerity measures appear to have led to a decline in hospital admissions but not to reductions in pharmaceutical consumption. The short-term effects examined in this paper suggest that austerity measures have had mixed success in protecting patients from reduced health care access, but there remains an important need to actively monitor the wider long-term health impact of the economic crisis.

Pensions health and retirement

Kompal Sinha, Centre for Health Economics ,Monash University

Anthony Harris ,Centre for Health Economics, Monash University

The aim of paper is to assess the level of income needed in retirement to maintain a satisfactory life and slow the rate of health decline. This is an alternative to the usual assessment of the adequacy of income in retirement based on pre-retirement income replacement. Using the HILDA data from Australia, this paper estimates the short and long term health effects of retirement accounting for the simultaneity of health and retirement in an instrumental variable panel data econometric model. We initially assume that human, and financial capital is exogenous at retirement. The results suggest that retirement has a positive effect on health and wellbeing initially but in the longer term has a negative effect on health mitigated by pension income and wealth. Health in the bottom income quintile wears out a good deal faster after retirement than does health in the top quintile, and in the bottom quintile men’s health deteriorates more rapidly than women’s health.

Assessment of Community Based Health Insurance In Sunsari Disrtict
Red Herring in Vistula River - New Evidence on Time to Death
Authors: Maciej Lis

The aim of article provide evidence on the role of age and proximity to death as drivers of health care expenditure (HCE). For our analysis a unique dataset on 14-types of HCE by age, sex and distinction for decedents and survivors has been delivered by Polish National Health Fund. We decompose the differences in health expenditure of 1-year cohort groups to quantify the contribution of survivors, decedents, mortality-rate and population changes. Then we compare the effects of assuming age-dependence and proximity-to-death-dependence for total health care expenditure. We find out that HCE depend on the proximity to death, but age-dependence cannot be left out. We also quantify the effects of both models for ageing to show that their implications hugely contradict. Using exponential model with parameter transition of cost increse before death we show that the health expenditure start to rise at about 10 years before death and that the implications of time-to-death and age-dependent model are considerable for the effects of ageing on health care expenditure and public finance.


Global efforts in health over the last decade have been towards achieving universal coverage for all populations. Public sector involvement in the achievement of this cannot be over emphasized but the role of the Private sector has rarely been well understood. Although most private health care enterprises operate for profit, many non-profit organisations also exist, avowing religious and charitable motivations. In some LMICs, private sector health care largely serves better-off people; in others, many of the poor rely on private provision. This economic and social patterning of private sector organisation is partly shaped by, and interacts with, the organisation and behaviour of the public sector in health care. The private sector can therefore only be understood and effectively regulated by understanding the mixed health systems of which it forms part. Both Private and Public sector can invest positively in Health. Private-sector health provision with public financing is commonly thought to offer the best combination to ensure efficient, high-quality, low-cost primary health care. Several health system factors affect the functioning of the private sector as a whole: the structure and performance of the public health-care sector, the structure of the private sector, the characteristics of patient demand for health care, and regulation of the private health-care sector. There are challenges created by Private sector listed above and also approaches suggested to address them. Also listed are methods by which these challenges can be solved and the facility level where each of these readily applies. All these are covered in this paper.

Alternative economic perspectives on the overconsumption of health care
Authors: Martin Hensher; John Tisdell; Craig Zimitat

Increasing attention has been paid in recent years to the problem of “too much medicine”, a shorthand term which describes situations in which patients receive unnecessary treatments which will provide little or no benefit to them, yet will potentially expose them to the accompanying risks of harm.  Despite this phenomenon clearly constituting an inefficient utilization of health care resources, it has received limited attention from health economists to date.

This paper considers “too much medicine” as a form of overconsumption, drawing on concepts from the ecological economics and sustainable consumption literatures.  It then reviews research from health economics, behavioural economics and ecological economics, to identify possible explanations for and drivers of overconsumption in health maintenance.  This seems to be the first time evidence from these studies has been merged, offering a novel contribution to the theatre of operations.

Overconsumption of health care represents a form of misconsumption, which occurs when 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 the provision of unnecessary services under various circumstances is one manifestation of this imperfection.  The behavioural economics evidence provides rich insights on why the actual practice may depart from an “evidence-based” approach (the presumed basis for any perfect agency relationship).  Moreover, behavioural findings on health professionals’ strategies for dealing with uncertainty and to avoid 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 to patients.  Meanwhile, 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.

Cost Effectiveness of Aggressive Risk Factor Management in Atrial Fibrillation
Authors: Rajeev Pathak; Michelle Evans; Melissa Middeldorp; Abhinav Mehta; Rajiv Mahajan; Darragh Twomey; Anand N. Ganesan; Walter Abhayaratna; Dennis H. Lau; Prashanthan Sanders

Investing in primary health care reduces the risk of diabetes-related hospitalisation of Aboriginal and Torres Strait Islander people with type 2 diabetes in north Queensland, Australia
Authors: Odette Gibson; Robyn McDermott; Adrian Esterman; Ming Li; Mark Wenitong; Leonie Segal

Objective: To estimate the impact of per capita primary health care (PHC) resourcing on the risk of diabetes-related hospitalisation over a 5 year period (2000-2005) in a cohort of Aboriginal and Torres Strait Islander Australian adults with type 2 diabetes (T2DM).

Design: Retrospective cohort study using linked community survey data, hospitalisation and death records.

Setting: Twenty one remote communities in far north Queensland, Australia.

Participants: Adults with existing or diagnosed with T2DM during a health check offered between1999-2000 (n=366).

Main outcome measure: Diabetes-related hospitalisations

Results: There was an inverse relationship between per capita PHC investment and the risk of diabetes-related hospitalisation over a 5 year period. Each AUD $1,000 per capita PHC spending was associated with a 24% reduction in hospitalisation risk (adjusted RR = 0.76, 0.60 to 0.95). This effect was strongest for extra spending on Aboriginal and Torres Strait Islander health workers (adjusted RR=0.21, 0.06 to 0.80) and medical officers (adjusted RR = 0.22, 0.05 to 0.95), but for extra employment (i.e. FTE) of medical officers (adjusted RR = 0.10, 0.01 to 1.01).

Conclusion: Investing in PHC in an under-served remote high risk population with T2DM prevents diabetes-related hospitalisations. Aboriginal and Torres Strait Islander health workers contribute significantly, as members of a multi-disciplinary PHC team, to reducing the risk of diabetes-related hospitalisations of people living in remote areas with T2DM.

Hip fracture rates and outcomes in the elderly Australians: trends in the 21st century and projections for the future
Authors: Dawei Huang; Wichat Srikusalanukul; Alexander Fisher

Aims: To assess trends in numbers, incidence rates and short-term outcomes of hip fracture (HF) among the elderly in the Australian Capital Territory (ACT) over a 15-year period (2000-2014) and project HF numbers and rates up to 2050.

Methods: Data on all HF patients aged 60 years and over in ACT were analysed in 5-year periods (2000-2004, 2005-2009, 2010-2014). Age- and gender-specific rates were calculated from ACT population data (Australian Bureau of Statistics, Series B). The projected rates and numbers of HFs were estimated by two models: binomial regression and Poisson regression.

Results: The annual number of HFs increased from 239+/-25 in 2000-2004 to 260+/-40 (8.7%) in 2005-2009 and 317+/-27 (+32.6%) in 2010-2014, with the proportion of aged 85 and over 40.0%, 44.3% and 49.4%, respectively, while the average incidence rates (cases/100,000 population/year) decreased from 597 to 534 (-10.6 %) and 531 (-11.1 %), and the female: male ratio was 2.3, 2.1 and 2.4, respectively.  Both the length of hospital stay (11.3+/-14.9, 11.6+/-18.74 and 12.5+/-15.4 days) and in-hospital mortality (6.61%, 7.05% and 7.43%) showed a mild non-significant increase. The total number of HFs in ACT will reach 515 (+115.5%) in 2030 and 706 (+195.4%) in 2050 (binomial model), or 473 (+ 97.9%) and 594 (+148.5%), respectively, (Poisson regression), whereas the HF rates are expected to decrease to 512.3 (-14.2%), and 477.5 (-20. 0%), or 470.5 (-21.2%) and 401.7 (-32.7%), respectively, with the female: male ratio  of 1.81 and 1.85, or 1.85 and 1.90, respectively. In Australia the number of HFs may reach 36,700 in 2030 and 47,800 in 2050 (binomial model), or 33,700 and 40,200, respectively (Poisson regression).

Conclusions: Despite declining HF incidence rates, the absolute number of HFs among the elderly (about 50% aged 85 years) continue to increase and may almost double by 2030 and triple by 2050.

The challenges of undertaking a cost benefit analysis of a large scale, multifaceted community-based nutrition project in Indonesia
Authors: Lisa Cameron; Paula Lorgelly; Kompal Sinha

One in three children under five in Indonesia is stunted. Stunting negatively affects future productivity, as stunted children are at a higher risk of experiencing chronic disease, impaired cognitive development and reductions in academic achievement. The a priori economic argument for developing programs to address stunting would thus appear strong. Increasingly though, to justify investment in such health initiatives, governments and funding agencies require a calculated estimate of a program’s expected monetary return. Indonesia’s Community-based Nutrition Program (CBNP) is a large-scale, complex, nutrition project with a budget in excess of USD150m. Its activities include the provision of conditional cash transfers to villages (with the promise of larger future grants if health indicators improve); training health providers; conducting sanitation activities; providing micronutrients to pregnant women and young children; results-based financial incentives to health providers; and a communications outreach campaign. We were tasked with calculating a single economic rate of return (ERR) for the entire project, ERRs for specific project components, and the returns flowing to the poor and women. Budget costs were compared to estimated benefits – comprising projected future increases in individuals’ incomes associated with the improved productivity resulting from reductions in low birth weight, stunting and malnutrition, and savings to the health sector from diarrhoea and chronic disease averted. Benefits flowing from the economic stimulus associated with the cash grants were also estimated. We highlight the challenges of undertaking a modelled economic evaluation in a lower-middle income country – including identifying the (often scarce) relevant evidence of the effects of the various interventions and particularly the monetary benefits; defining beneficiary groups; the difficulty of modelling benefits for separate project arms when there are likely to be interactions between the program’s different components; and the attempts to model uncertainty and sensitivity in the results.

Changing continuity of care in Ausralian General Practice
Authors: Michael Wright; Jane Hall; Kees van Gool; Marion Haas

Continuity of care is seen as a core component of high quality primary care. We seek to understand whether continuity of care with a GP and a practice is changing for Australian general practice patients.

We use data from the Australian Longitudinal Study on Women’s Health (ALSWH)- a large (n=50,000+) longitudinal study of 4 cohorts of Australian women since 1996, linked to administrative data.  Participants have been surveyed ~3 yearly about health service usage and health status since 1996. We use data for the young cohort (aged 18- 23 in 1996) and middle cohort (aged 45-50 in 1996).  Patient self-reported continuity of care (at both practice and GP level) is the dependent variable in our model.  Pooled OLS and panel data techniques have been conducted analysing the relationship between continuity of care, and patient related explanatory variables- including age, rurality, health status, and health service usage.

In the young cohort, the percentage of women seeking all their care from one GP has decreased by 28% through the 15 years of survey data, while women seeking all their care from one practice has increased by 21.5%.  For the middle cohort, the percentage of women reporting attendance with one GP has increased by 2% through the survey waves, while those attending one practice has increased by 11.6%.  Regression analysis shows multiple patient related variables associated with increased likelihood of seeking continuity of care at both a provider and practice level.

Conclusion. Analysis suggests an increasing trend for Australian women to seek continuity of care from a general practice.  This is despite no formal system of practice registration. Multiple differences exist between patients seeking continuity with a practice, and those seeking continuity with a GP.

High Spending on Maternity Care in India: What are the Factors Explaining It?
Authors: Moradhvaj

Background and Objectives
High maternity-related health care spending is often cited as an important barrier in utilizing quality health care during pregnancy and childbirth. This study has two objectives: (i) to measure the levels of expenditure on total maternity care in disaggregated components such as ANCs, PNCs, and Natal care expenditure; (ii) to quantify the extent of catastrophic maternity expenditure (CME) incurred by households and identify the factors responsible for it.

Methods and Findings
Data from the 71st round of the National Sample Survey (2014) was used to estimate maternity expenditure and its predictors. CME was measured as a share of consumption expenditure by different cut-offs. The two-part model was used to identify the factors associated with maternity spending and CME. The findings show that household spending on maternity care (US$ 149 in constant price) is much higher than previous estimates (US$ 50 in constant price). A significant proportion of households in India (51%) are incurring CME. Along with economic and educational status, type of health care and place of residence emerged as significant factors in explaining CME.

Findings from this study assume importance in the context of an emerging demand for higher maternity entitlements and government speding on public health care in India. To reduce CME, India needs to improve the availability and accessibility of better-quality public health services and increase maternity entitlements in line with maternity expenditure identified in this study.

Cost-effectiveness implications of displacement of oncology therapies
Authors: Philip Haywood, Rosalie Viney, Marion Haas

The development of new therapies in oncology has the potential to displace older therapies from their current positions. This may impact on the cost-effectiveness. This paper evaluates the impact of displacement on cost-effectiveness and models the outcomes.

RCTs have been synthesized via a meta-analysis and conclusions drawn about the impacts of displacement on characteristics of oncology protocols (a collection of therapies). Specifically the impact of a protocol being displaced from one of therapy to the next line of therapy has been assessed on overall survival, progression free survival and toxicity.
The impact of a protocol being displaced a line of therapy is to decrease a protocols effectiveness and increase the rate of toxicity per unit time. The line of therapy a protocol is used within impacts on the characteristics of the protocol. However the size of the impact is uncertain because of the data reported in the trials and the necessary restrictions on the methods of synthesis.

The potential impacts of the characteristics of a protocol altering as it is displaced are explored using modelling. The impact of displacing a protocol is to increase the cost-effectiveness of the protocol. Increasing the toxicity and reducing the effectiveness of a therapy in displacing it from one line of therapy to the next increases the cost-effectiveness of the therapy. The net economic loss associated with the increase in cost-effectiveness is highly variable. Key determinants include the mechanism of reimbursement.

The cost-effectiveness of a protocol is dependent on which line of therapy it is used in. Without pricing changes, on average, the cost-effectiveness worsens as a protocol is displaced from one line of therapy to the next. However the size of the opportunity cost of the health forgone from the worsening cost-effectiveness is highly variable.

Anchoring vignettes and the EQ-5D: Adjusting for systematic differences in reporting behaviour
Authors: Rachel Knott; Paula Lorgelly; Nicole Au; Bruce Hollingsworth

Preference-based measures of health are often used in economic evaluations to calculate quality adjusted life years (QALYs). Increasingly they have been used as a measure of population health status; for example, comparisons of EQ-5D health profiles and utility values have been made by socio-economic status and behavioural risk factors. However the EQ-5D as a subjective measure is likely to suffer from mis-reporting and response category differential item functioning (DIF), like other self-rated measures of health, and failure to correct for it may lead to conclusions that are misleading.

This paper explores the use of anchoring vignettes to test and correct for systematic differences in responses and improve inter-group comparisons of EQ-5D profiles and indices. We apply hierarchical ordered probit (HOPIT) models to individual domain responses and assess the impacts of DIF in EQ-5D reporting according to gender, age, income and country of birth. We find considerable variation in the use of response categories across all EQ-5D domains, which alters relative differences in EQ-5D summary indices across respondent sub-groups.

The growth of linked hospital data use in Australia: A systematic review
Authors: Michelle Tew; Kim Dalziel; Dennis Petrie; Philip Clarke

To describe the use of hospital data linkage for research purposes in Australia.

A systematic review was performed using PRISMA checklist. Databases were searched using key terms for linkage and hospital. All journal articles available until December 2014 using individual patient-level data linked with hospital records were included. Information on publication year, state(s) involved, type of data-linkage, disease area and study purpose were extracted.

A surge of publications utilizing hospital data linkage is observed in the last 15 years. Of 629 total articles, 321 (51%) were from WA and 203 (32%) from NSW. Publications from WA have increased since the establishment of the first data linkage system in 1995 and NSW has made significant contributions since 2011. Small increases in publication numbers have also been observed from Victoria, South Australia/Northern Territory and Queensland in the last five years. Linkage to state hospital databases (56%) was the most common linkage employed. Only 8% of hospital data linkage was to non-hospital databases. The most common research areas were on factors influencing health status or health services (19%), circulatory diseases (15%) and injury and external causes (14%). 73% of publications were epidemiological with only a small proportion focusing on costs, informing policy, or economic evaluations.

84% of publications were from NSW and WA, while other states significantly lag behind in their use of data linkage for research purposes. The observable growth in publications in WA and NSW clearly showcases the underutilized opportunities in the other states for data linkage to add value in health services research. There is a wealth of useful data routinely collected in Australia’s hospital system and the barriers to access linked health datasets impedes efficient resource use and gains in knowledge through research.

Applying Consumer Choice Theory to Health Technology Assessments in Australia - A study of adolescent patients with Type 1 Diabetes in Western Australia using a Discrete Choice Experiment to elicit preferences for insulin therapy
Authors: Elizabeth Geelhoed; Elizabeth Davis; Timothy Jones; Martin De Bock; Richard Norman; Natrisha Barnett

Type 1 diabetes mellitus (T1DM) patients can decide how they administer insulin – typically, by injection or insulin pump. The development of continuous glucose monitors offers sensor-augmented insulin pump therapy (SAP) as the gold-standard therapy option. While SAP delivers improved glycaemic control and therefore reduces the risk of diabetes-related health complications, cost-effectiveness has only been demonstrated in a subset of patients prone to severe hypoglycaemia. The Australian Government does not currently subsidise SAP. Funding for SAP is now on the political agenda with both the Coalition and Labor Party announcing funding schemes for patients under the age of 21 if elected in 2016. The Medical Services Advisory Committee will need to review the health economics of the proposed subsidies. Therefore, it is timely to examine cost-effectiveness of SAP in adolescents with T1DM who often experience difficulties adhering to treatment, resulting in costly complications and influencing long-term disease management. We use a novel approach – a Discrete Choice Experiment survey – to apply consumer choice theory and determine treatment benefits to adolescent patients, generating additional quality-of-life measures.  A sample of 200 adolescent patients with T1DM in Western Australia will be recruited to the survey. Initially, focus groups will be held to identify the appropriate treatment attributes for inclusion in the survey. Demographic information will be collected to assess the impact of family structures, education levels and private health insurance on treatment choices. A multinomial logit analysis will provide quantitative insight into the relative importance of each treatment attribute for male and female adolescent patients. Parents will also be asked to complete a Discrete Choice survey with a cost attribute to determine how a financial burden influences final treatment decisions. Preliminary results will be available in September 2016.

Projection of economic impacts of chronic conditions leading to early retirement of older working age Australians: Results from a microsimulation model Health&WealthMOD2030.
Authors: Deborah Schofield; Rupendra Shrestha; Michelle Cunich; Simon Kelly; Lennert Veerman; Robert Tanton; Megan Passey

Premature retirement due to illness can have significant economic impacts. Individuals are affected through reduced income and savings; governments through decreased taxation revenue and increased expenditure on income support payments. These economic impacts are likely to increase in future with an ageing workforce and increasing trends in disease prevalence.

We have a developed a microsimulation model, Health&WealthMOD2030 to estimate the projected economic impacts of illness leading to early retirement to 2030, sourcing the base population from the Australian Bureau of Statistics 2003 and 2009 Surveys of Disability, Ageing and Carers datasets. Projected estimates of income, taxation, income support payments, savings and superannuation from a dynamic microsimulation model APPSIM and the disease trends from ACE-prevention models were synthetically matched with the base population to project forward the economic impacts of early retirement due to ill health to 2030 for the Australian population aged 45 to 64 years old.

This paper provides projections of the economic costs associated with illness-related early retirement for both individuals, in terms of income lost, and government, in terms of taxation revenue lost and increase in government support payments, for every five years from 2010 to 2030. On average, annual earnings lost of those not in the labour force due to illness, when compared to those in full time employment and have no chronic condition, is estimated to be about $43000 in 2010, which is estimated to increase to about $60000 by 2030. The estimated annual national loss of earnings due to illness-related early retirement is about $11 billion in 2010, estimated to increase to about $20 billion by 2030.

These results highlight the need for effective prevention or treatment of illness to keep older working age Australian in the labour force to reduce the immediate and the long-term negative economic consequences.

A qualitative investigation of the emergence of demand-induced supply for bariatric surgery: diversity of patient perspectives and implications for economic evaluation of bariatric surgery.
Authors: Julie Campbell; Douglas Ezzy; Martin Hensher; Amanda Neil; Alison Venn; Melanie Sharman; Andrew Palmer

Background: A key market failure in healthcare is asymmetry-of-information between the consumer/supplier where the level of knowledge and expertise is weighted to the supply side. In the information age, patients may be more empowered in their negotiated relationship with healthcare providers. Importantly, information that empowers the consumer and underpins the emergence of ‘demand-induced supply’ (DIS) (patients demanding and receiving care that their clinician would not otherwise have offered) has implications for economic evaluation of bariatric surgery.
Objective: We employed qualitative research methods (QRMs) to investigate the emergence of DIS for bariatric surgery by identifying important information drivers (including information quality), and the divergence of ‘important’ information pre and postoperatively.
Methods: Ten semi-structured focus groups of people who were waitlisted/undergone bariatric surgery were conducted (n=49). Thematic analyses were employed to analyse verbatim transcripts. Inductive/deductive theory building generated global themes informed by the pre-existing economic theories of the principal-agent relationship and asymmetry-of-information.
Results: We found a divergence between the ‘before’ and ‘after’ surgery information drivers. In particular, we found that preoperative information relevant to psychosocial health domains (‘magic bullet effect’, ‘seesawing weight’, stigmatisation/discrimination) supports demand-induced supply for bariatric surgery. Information that emerged as being highly relevant after surgery related to ‘food addiction’, ‘mindset’, food practices and physical symptoms (eg ‘reflux’). We also found that relevant preoperative information sources (eg family/friends/internet) were different from after surgery (surgeon, allied-health eg dietician/psychologist).
Discussion: Our study is the first to adopt QRMs to investigate the emergence of DIS for bariatric surgery. By exploring patients’ ‘lived’ experiences, QRMs have elicited information drivers that would otherwise not be identified nor fully understood. We recommend that patient information sources be more targeted towards the psychosocial health domains preoperatively and ongoing postoperatively.

Social Network and Mental Health: Evidence from the Rural-to-Urban Migration in China
Authors: Xin Meng; Sen Xue

This paper attempts to identify the causal effect of social network on mental health of the Chinese rural-to-urban migrants. The Chinese migrants are a vulnerable group to the mental diseases. The empirical analysis is conducted based on a unique migrant survey from the Rural-to-Urban Migration in China Project, which includes the most up-to-date information about Chinese rural migrants. Using OLS and FE models, we find that larger network is significantly correlated with better mental health. To mitigate the endogeneity bias, we employ a novel instrumental variable approach. In particular, we use the rainfall at migrants’ hometown and mobile phone ownership as the instrumental variables. Both IV and FEIV estimates indicate that social network is beneficial in reducing mental health problem, and the effect is larger and significant for the migrants who are less mobile, have smaller network or are with more serious mental problem.

Economic Implications of Cardiovascular Disease Management Programs: Moving Beyond One-off Experiments
Authors: Shoko Maru; Joshua Byrnes; Melinda J. Carrington; Simon Stewart; Paul A Scuffham

Despite the expectation that cardiovascular disease management programs (CVD-MP) may reduce costs while improving health outcomes, the results of cost-effectiveness analyses remain equivocal. Substantial variation in economic analyses of CVD-MPs hinders not only the proper assessment of cost-effectiveness but also the identification of potential predictors of cost-effectiveness. The objective of this review is to explore how much of the variability of cost-effectiveness can be explained by the characteristics of patients or intervention evaluated rather than the differences in study methodology and reporting practice.

Based on two systematic reviews we recently conducted, we further explored the impact of methodological and reporting variation on the cost-effectiveness of multi-component CVD-MPs by introducing scenarios that could lead to different policy, funding or clinical decisions. We then focused on ambiguity or equivocation, an issue most commonly observed in the published reports on CVD-MPs, which hinders the assessment of net intervention effects and the generalizability of findings.

We identified key limitations around which the research of CVD-MPs tend to pivot, such as poor third-party reproducibility, variations in handling of costs arising from improved survival, competing risks surrounding hospitalization events, or the assumed durability of post-intervention effects. To date, these limitations have hindered the ability to move beyond one-off experiments (a single study-based economic evaluation) and time-/place-specific attributes, leading to the substantial variation in the economic implications of CVD-MPs.

The current evidence supporting CVD-MP is affected by both methodological variation and inadequate or insufficient reporting of cost components, thereby true heterogeneity of interest is obscured. Further standardization using practical tools used in our recent systematic reviews such as a checklist for the reporting standards of health economic evaluation reporting will increase transparency and comparability across studies. These efforts should help translate research findings into unambiguous recommendations for decision makers.

Investigating the relative value of health and social care related quality of life using discrete choice
Authors: Brendan Mulhern; Richard Norman; Richard DeAbreu Lourenco; Rosalie Viney

A key outcome in the economic evaluation of health interventions is the Quality Adjusted Life Year (QALY). The quality of life (QoL) weight is generally provided by preference-based measures of health (e.g. EQ-5D).  However, interventions can also result in improvements in non-health related QoL (e.g. social care), but currently these effects are only partially captured.  The aim of this study was to understand the relative relationship between, and preferences for, health and social determinants of QoL (described using the EQ-5D-5L and ASCOT respectively). These were assessed jointly using a discrete choice experiment (DCE).

An online DCE was carried out in Australia.  Respondents were presented with choice sets including two profiles with attributes from both the EQ-5D-5L and ASCOT.  Each respondent completed 15 tasks from an underlying design of 300 choice sets.  Analysis used standard approaches to analyzing DCE data, employing conditional logit modelling to estimate coefficient decrements for each level of each attribute to examine the relative importance of each.

The results suggest that the levels of the majority of the dimensions are ordered as expected.  There is clear trading off between health and social care, indicated by differences in the magnitude of the coefficients across the different aspects of QoL included in the DCE tasks.  Respondents reported been able to conceptualise the states presented and complete the tasks, but there was some drop-out.

The results improve our understanding of how aspects of health related and social care related quality of life are traded against other, and the relative importance of each.  We have tested a possible choice based approach that will allow us to make inferences about QoL based on data obtained from different preference based instruments. The data also provide a basis for stimulating further research in this area.

Migrant Health in Australia - Existing Literature and New Results
Authors: Nicholas Biddle; Samuel G. Weldeegzie

In this paper, we review the existing literature on migrant health from historical and methodological perspective and expand the current analysis using the most recent 4 waves of data from HILDA to re-examine the association between migration and self-assessed health and whether self-assessed health of migrants deteriorates the longer they stay in Australia. Using ordered probit model, results from both cross-sectional and panel data random effects suggest that migrants from English speaking countries have higher self-assessed health than native born while migrants from ‘other’ countries tend to have no difference or worse health relative to natives. Furthermore, migrants’ health deteriorates the longer they stay in Australia controlling for a range of covariates such as age, gender, education, employment, and income. This is consistent with previous findings from the literature not only in Australia but also in Canada and the USA. In addition, we investigate if results are are sensitive to controlling pre-migration characteristics such as education and labour market outcomes.

The cost-effectiveness of different population screening strategies for haemochromatosis in Australia: a state-transition model
Authors: Barbara de Graaff; Amanda Neil; Lei Si; Kwang Chien Yee; Kristy Sanderson; Lyle Gurrin; Andrew Palmer

Hereditary haemochromatosis is one of the most common genetic disorders amongst populations of northern European ancestry. Clinically it is characterised by iron overload, with excess iron stored in the parenchymal tissues of the liver, heart and pancreas. As early symptoms are non-specific, diagnosis is often delayed, leading to morbidity and mortality. Population screening programs have been suggested to reduce the associated burden of disease, however a paucity of robust health economic data has been cited as a major barrier. The aim of this study was to analyse the cost-effectiveness of screening for C282Y homozygote haemochromatosis in Australia.

A Markov model compared four adult screening strategies: the status quo (cascade and incidental screening), genotyping with blood and buccal cell samples, and screening using sequential transferrin saturation (TfS) followed by HFE-genotyping; and two neonatal strategies: the status quo and HFE-genotyping. Five Markov states based on increasing disease severity and death were used. The target populations were 30-year-old males and 45-year-old females, of northern European ancestry, and neonates irrespective of ancestry. Lifetime costs (2015 Australian Dollars (AUD)) and quality-adjusted life years (QALY) discounted at 5% annually were estimated from the perspective of the government. Univariate and probabilistic sensitivity analyses were performed.

All screening strategies for males were cost-effective in comparison to the status quo, producing ICERs of AUD1,673 (genotyping blood), AUD4,103 (TfS), and AUD15,233/QALY gained (genotyping buccal). For females, only the TfS strategy was cost-effective, with an ICER of AUD10,195/QALY gained. Genotyping neonates produced cost savings and improved effectiveness, thereby dominating the status quo. One-way sensitivity analyses identified discount rates and screening age as having the greatest impact on results.

This model suggests that genetic and TfS screening are likely to be cost-effective strategies for adults, and for neonates, genotyping dominated the status quo.

Expenditure on non-communicable diseases in China: Results from a National Health Accounts Framework
Authors: Tiemin Zhai, Yuhui Zhang, Peipei Chai, Qiang Wei, John Goss

Rationale:Rapid socio-economic development, dramatic changes in people’s way of life and population aging have led the case prevalence of non-communicable diseases (NCDs) in China to increase rapidly, from 15.8% in 1998 to about 20.0% in 2008. These trends beg a series of questions. Most notably, how many resources have been spent in preventing, managing and treating NCDs so far; what diseases consumed most of health resources, and how much was paid by individuals so that the country is able to formulate health financing policies that balance the needs of the population and the country’s capacity to pay for services.

Objective: To analyse expenditure on prevention, management and treatment of NCDs by financing source, health provider and health function in China.
Methodology:Analysis was based on the latest version of the OECD and WHO System of Health Accounts methodology. Relevant data for the study were drawn from 3 major sources, namely the hospital revenue and expenditure data from the Ministry of Health, individual service utilization data obtained from a field survey conducted in 4 provinces and China’s 4th National Household Health Survey.

Result: Total expenditure on NCDs accounted for nearly 70% of total health expenditure(THE), but of these less than 2 percent were spent on prevention. Of those NCDs, CVDs consumed about 34% of the expenditure. Results also showed that reimbursement through health insurance was relatively lower for NCDs.

Conclusion: NCDs accounted for a large proportion of THE, but we also know that a large promotion of NCDs can be prevented by appropriate primary health care interventions. Therefore, the reimbursement policies should be direct towards encouraging these types of interventions. On the other hand, if these types of interventions discouraged by the reimbursement policies this will raise health financing sustainability issues.

The implications of different methods for modelling time from event til death for health economic analyses
Authors: Tom Lung, Dennis Petrie, Alison Hayes, Bjorn Eliasson & Philip Clarke

Aims: Estimating time after event parametric models from survival analysis are often used to extrapolate into the future for predicted costs and outcomes. These predictions are used in cost-effectiveness analysis to form the basis of medical decision making. This paper aims to investigate the implications of using different methods for estimating the risk in the present and in the future.

Methods: This study is based on data from the Swedish National Diabetes Register linked to patient level hospital records, prescription data and death records. We selected patients with Type 1 diabetes who visited a clinic 2002-2010 and experienced a major cardiovascular complication after their clinic visit. We estimated a parametric model for mortality following a cardiovascular complication in two ways: Using age as the underlying risk; Using time from CVD event as the underlying risk. A simulation model estimating cardiovascular incidence, mortality and a competing risk model was used for illustrative purposes in a cost-effectiveness setting.
Results: Immediately following a CVD event, there is an increased hazard, which subsides in the medium term but increases again in the long-term, mimicking the shape of a “bathtub”. The results suggest using age as it adjusts for this effect post-event, producing better predictions in the future than using time from event. When extrapolating into the future, the two models predict opposite sloping directions of hazard which has different implications for cost-effectiveness analysis of interventions following a CVD event.

Conclusions: When estimating parametric models following a CVD event in Type 1 diabetes patients, our paper suggests using age as the underlying hazard provides better predictions when using these models to predict long-term outcomes and costs.

What is the best model to use to evaluate an outpatient orthopaedic service - DES or Markov cohort?
Authors: Lachlan Stanfield; Tracy Comans; Paul Scuffham

Social Determinants of HIV: A Study of Women in Kerala
Authors: Vaibhav Khandelwal

Are Banks Bad for Boys? Estimating the Effect of Banks on Child Mortality, Education, and Fertility in Rural India
Authors: Daniel Rosenblum

I investigate whether a large-scale bank expansion program affected parents’ decisions to invest in the health and education of their children. From 1977 to 1990, the Indian government implemented a new licensing program to encourage the construction of banks in under-served rural communities. The timing of the bank expansion program is used as an instrument to account for the possible reverse causality of child mortality or education rates affecting bank expansion. An empirical analysis using large-scale Indian surveys finds that states with a more rapid expansion of rural banks did not have significantly lower child mortality overall. However, in households with a first-born daughter, in which discrimination against daughters and in favor of sons is exacerbated, excess female mortality declines with an increase in banks. This occurs through higher male mortality rather than lower female mortality. Similarly, an increase in banks has no effect on daughters’ education, but it reduces sons’ years of education. Both of these effects occur in a context of more banks causing lower fertility and a reduction in poverty rates, which if anything should lead to reduced child mortality and higher education levels.

The Effects of Air Pollution on Health: Evidence from China
Authors: Xiaobo He; Rong Zhu; Hongjia Zhu

Using three waves from the China Health and Nutrition Survey (CHNS, 2004, 2006 and 2009), this paper examines the causal effects of air pollution on health in China. The measures of health rely on results of biomarker testing. In addition, this study sheds light on people’s response to local air pollution. To mitigate potential endogeneity bias in ordinary least squares (OLS) estimates, this study utilizes wind speed as an instrumental variable (IV) for the endogenous variable of interest, i.e. air pollution measured by Air Pollution Index (API). The IV estimates show that more severe air pollution causes lower density of hemoglobin whereas higher density of platelet, white blood cell, insulin and uric acid in blood. This study also provides evidence that heavier air pollution leads to changes in human behavior: i) more likelihood of having supplementary medical insurance, ii) less likelihood of drinking alcohol everyday, and iii) less consumption of beer and wine per week.

Preferences across attributes for use in health care priority setting – a systematic review of empirical evidence
Authors: Yuanyuan Gu, Emily Lancsar, Cam Donaldson, Peter Ghijben, Jim Butler

Achieving efficiency in non-market decision-making in health care is often interpreted as requiring QALY maximisation. This approach implies that QALYs are homogeneous across a population, i.e. that “a QALY is a QALY is a QALY” to whomsoever it accrues. However, QALY maximisation may not result in the most equitable distribution of QALYs across society. QALY gains across a population can differ over at least three dimensions: the characteristics of beneficiaries, the characteristics of health gains, and other important contextual factors.

In this review we search for studies using empirical data to elicit preferences across attributes for use in health care priority setting. The objectives of the review are to identify a list of attributes that can be classified into the three dimensions, to extract distributional weights, and to review preference elicitation methods and approaches that have been used for estimating distributional weights. General patterns from the data are inferred, pros and cons of each method are discussed, and future research directions are suggested.

The empirical evidence in these papers has concentrated mainly on age and severity. Overall, size of health gain, severity, age, lifestyle, and having dependants have been found to be important factors for prioritisation; gender and socioeconomic status have been found to be less important; and a premium for end-of-life treatment has not always been supported. It is implausible to synthesise results and draw firm conclusions because of heterogeneity in the use of approaches and questionnaires. Only a small number of studies estimated distributional weights, mostly for age or/and severity. Neither an agreed set of weights nor an agreed method has emerged from the literature. Early studies typically examined the importance of factors in isolation while the recent trend has been towards more realistic scenarios where multiple attributes are allowed to vary.

Assessing changes in stroke survival for the Northern Territory public hospitals, 1992-2013: A marginal structural analysis
Authors: Yuejen Zhao

Objective: To investigate changes in stroke long-term survival for the public hospitals in the Northern Territory (NT) using routinely collected hospital data.

Design and setting: a longitudinal study of stroke patients consecutively admitted to the public hospitals between 1 July 1992 and 30 June 2013.
Main outcome measures: Stroke survival hazard ratios (HR) by time trend, key demographics, stroke subtypes and comorbidities. Kaplan-Meier method and proportional hazards Cox regression were used for survival analysis. A marginal structural Cox model was applied to adjust for time-dependent age confounder and loss to follow-up.

Results: There were 4754 stroke patients admitted over the study period. Of the total, there were 3540 (74.5%) new cases and 837 (17.6%) recorded deaths due to stroke. The distribution of stroke type was ischaemic stroke 46.9%, haemorrhagic stroke 23.8%, and type undetermined 29.3%. Age of stroke onset among Indigenous patients was 51.7, 12.3 years younger than non-Indigenous patients (64.0). The marginal structural survival analysis indicated that Indigenous stroke patients were more likely to die than non-Indigenous patients (HR=1.65, P

An Economic Evaluation of Deep Brain Stimulation for Patients with Tourette's syndrome: An Initial Exploration
Authors: Tho Dang, David Rowell, Jacki Liddle, Terry Coyne, Peter Silburn & Luke Connelly

Background: To date, no economic evaluation of treating Tourette’s syndrome with deep brain simulation (DBS) has been published. The aim of this research is to present an initial exploration of an economic evaluation of DBS to treat severe TS.

Methods: We conduct a cost utility analysis (CUA), which compares the direct medical costs reported as $US and outcomes reported as quality-adjusted life years (QALYs) of DBS with best medical treatment (BMT). Our sample consists of 17 patients who received DBS for severe TS at St Andrews War Memorial Hospital, Brisbane, Australia from September 2008 to February 2012. Clinical indices for (i) tic severity (Yale Global Tic Severity Score) and (ii) depression (Hamilton Depression rating Scale) and (iii) age were collected pre and post DBS. These clinical data were converted QALYs using standardized coefficients derived from a multivariate regression derived from a German sample of outpatients (n=200)

Results: The direct costs of DBS and BMT were estimated to be $USD 124,400 and $USD 34,180, respectively. DBS was estimated to increase health utility from 0.45 to 0.78. The ICER of DBS was estimated to be $USD 27,600 per QALY gained, which is lower than the nominal US Food and Drug Administration approved threshold of $USD 50,000 per QALY.

Conclusions: Our initial exploration suggests DBS is a cost-effective treatment for patients with severe TS. However, our results were sensitive to estimates of the costs adverse events. Future research will administer a survey of healthcare costs and QALYs to an international database of TS patients treated with DBS, with the aim of developing a more robust estimate of QALYs.

The effects of self-reported health: dealing with misclassification bias
Authors: Linkun Chen; Philip Clark; Dennis Petrie; Kevin Staub

Categories of self-reported health (SRH) are often used as a measure of health status. However, the difficulties with measuring health mean that getting individuals to select into SRH categories may involve misclassification. If neglected, misclassification can lead to substantial biases in the estimation of the effects of SRH on outcomes of interest. This paper studies the identification and estimation of nonlinear regression models where the key explanatory variable is SRH and two potentially misclassified measures of SRH are available. In contrast to linear regression models, standard instrumental variables and control function approaches do not allow consistent estimation of the coefficients of interest in nonlinear models. We show that, under suitable independence and conditional independence assumptions, the coefficients are identified from the joint distribution of the outcome and the two misclassified measures; and we propose a simple GMM approach to estimate these coefficients consistently. Comprehensive Monte Carlo simulations document the good small sample performance of the estimator under varying degrees of misclassification. Finally, we explore the issue empirically using the Household, Income and Labour Dynamics in Australia (HILDA) Survey, where a panel of individuals are asked the same question about their health status twice in some years, and a considerable number of individuals switch their stated health category when asked a second time.

Application of simulation modelling to reduce queues for orthopaedic outpatients in an Australian health service
Authors: Comans TA, Raymer M, Chang A, O’leary S, Knowles D,  Stanfield L

Aim: This paper describes the methods and results of a systematic review to identify instruments that have been used in measuring quality of life outcomes in older people, with a primary focus on preference based instruments suitable for application within economic evaluation in the aged care sector.
Methods: To identify instruments used to measure quality of life in older people, online databases searched were PubMed, Medline, Scopus, and web of science, PsycInfo, CINAHL and informit. Studies that met the following criteria were considered: 1) study population exclusively above 65 years of age 2) measured quality of life outcomes as indicators of health status or HRQoL through use of an instrument, and 3) published in journals in the English language after 1990.
Findings: The most commonly used generic preference based instruments were the EQ-5D, HUI3, and AQOL. Of the older people specific instruments, the ICECAP-O was the most commonly used instrument followed by the WHOQoL-Old, the OPQOL the CASP-19 and the ASCOT. Conclusion: In the absence of a single ideal instrument for cost utility analysis undertaken in the aged care sector, this review recommends the use of a generic preference based instrument, the EQ-5D to obtain QALYs, in combination with the OPQOL or the ICECAP-O or the ASCOT to facilitate measurement of broader quality of life as defined by older people.

Exploring heterogeneity in count data: A study of PBS utilisation in children with language impairment.
Authors: Paula Cronin


The use of count data to explore health utilisation is well documented and poisson regression models provide a standard framework for this type of analysis. In this paper I review and compare methods that deal with two forms of heterogeneity or over-dispersion in panel count models.I explore the Longitudinal Study of Australian Children K dataset to analyse one count variable- PBS utilisation. A central focus of this investigation was whether children who are screened as having language impairment (LI) have higher PBS utilisation and over what time periods.

This study seeks to explore the determinants of health care in different parts of the utilisation distribution. It exploits the panel nature of the data over five waves and provides insights into the timing of health care utilisation. It is the first Australian study that we are aware of that addresses this issue in an econometric framework.

A sample from the Longitudinal Study of Australian Children (LSAC) (n=3490, t=5 ) was estimated using negative binomial (random effects) models. I compare these models with the pooled poisson (robust SEs), pooled negative binomial and zero inflated negative binomial model to study the effects of language impairment (measured by PPVT (Peabody Picture Vocabulary Test ) on PBS utilisation (no of scripts).

The negative binomial (random effects) with Mundlak adjustment outperforms all models and the results show that having a positive language impairment screen at 4/5yrs is a significant predictor of between 0.76 and 1.33 higher PBS scripts for children in the highest income households. This is despite the lower income children reporting the highest rates of LI (36% screened). The results point to the existence of inequity in health care utilisation, which is found to be distributed according to wealth rather than according to need.

A Cost-Effectiveness Threshold for the Australian Healthcare System
Authors: Laura C Edney; Hossein Haji Ali Afzali; Terence C Cheng; Jonathan Karnon

Introduction Healthcare expenditure aims to improve health outcomes and reduce health inequities through the provision and allocation of effective and efficient health technologies and services. The effects of increased investment in healthcare expenditure on population health are not well understood in Australia. Such expenditure effects have been proposed as a proxy measure of the opportunity costs of healthcare funding decisions to inform an empirical estimate of an Incremental Cost-Effectiveness Ratio (ICER) threshold, against which the value of new health care interventions can be referenced.

Method Routinely collected data on healthcare expenditure and mortality and population survey data on Health-Related Quality of Life (HRQoL) are used to estimate a reference ICER for the Australian healthcare system controlling for differences in health care need and sociodemographics. Instrumental Variable Two-Stage Least Squares Regression was used to estimate the causal relationship from healthcare expenditure to mortality-related QALY effects, to which morbidity-related improvements in HRQoL were added to generate a reference ICER.

Results Results suggested that healthcare expenditure had a significant positive impact on both mortality- and morbidity-related QALY gains. The reference ICER was sensitive to the allocation of HRQoL effects to healthcare expenditure and to the assumed duration of effect. Other key uncertainties related to the coverage of the expenditure data and the assumed mortality effects in the year of expenditure.

Conclusion The estimated relationship between healthcare expenditure and QALY gains provides a starting point for discussions around the validity of the described method to provide an empirical estimate of a reference ICER for the Australian healthcare system that can be used to guide future funding decisions for new healthcare technologies.

Measuring income-related health inequalities with uncertain future health prospects
Authors: Gustav Kjellsson; Dennis Petrie;Tom Van Ourti

Measurement of health disparities is a key component for the assessment of health systems. The extent to which disparities in health are systematically associated with income has been proposed as a measure of disparities in realized health outcomes.

On average the poor not only have worse health than the rich but also experience a quicker deterioration in their health over time. However, by looking at realized health outcomes and trajectories, we ignore the variation in the health trajectories faced by poor and rich individuals. In particular we do not know whether the quicker expected average deterioration in the health of the poor is due to a homogenous negative expected impact experienced by all poor people or due to the poor being more exposed to possible negative shocks to their health. Individuals that are averse to uncertainty are likely to place more weight on avoiding the possibility of worse future health states.

This paper adds to the current literature on the longitudinal measurement of income-related health inequalities by developing methods which incorporate the level of uncertainty in future health prospects into the picture. Using data from the Australian Household, Income and Labour Dynamics in Australia (HILDA) Survey from 2002 until 2013 we find that the poor were not only expected to lose more health than the rich over time but they also faced greater uncertainty around their future health prospects than the rich.

Are fruit and vegetables good for our mental and physical health?
Authors: Redzo Mujcic

Education and Health Knowledge: Evidence from UK Compulsory Schooling Reforms
Authors: Agne Suziedelyte

The economic costs and consequences of providing antenatal lifestyle advice for women who are overweight or obese: the LIMIT randomised trial
Authors: Prof. Jodie Dodd; Sharmina Ahmed; A/Prof. Wendy Umberger; Prof. Jon Karno; Andrea Deussen

Maternal obesity is associated with adverse pregnancy and birth outcomes. The objective of this study is to evaluate the overall cost effectiveness of antenatal dietary and lifestyle interventions for pregnant women who are overweight and obese pregnant. The study uses data from a multicentre randomized trial conducted in three hospitals in South Australia. Women having a singleton pregnancy, between 10-20 weeks’ gestation and BMI≥25 were randomised to receive either standard care (n = 1104) or a comprehensive dietary and lifestyle intervention (n = 1108). Cost effectiveness analysis was completed considering two significant clinical outcomes of the trial: infants born to women receiving lifestyle advice were significantly less likely to have birth weights above 4000g and were.less likely to suffer moderate to severe respiratory distress syndrome (RDS) compared to infants born to women receiving standard care. Direct out-patient, in-patient and intervention costs for up to 4 weeks after birth of the baby were calculated. The SF-36 QoL was completed by participants at trial entry, 28- and 36 weeks of gestation and 4 months post partum. No significant mean cost differences were found between the two groups. However, the cost effectiveness acceptability curve (CEAC) illustrates that if $20,000 is the threshold value (i.e. the maximum policy makers would be willing to pay), then the probability of lifestyle advice being a cost effective intervention for reducing the risk of infants with birth weight above 4000g is 0.85 compared to 0.15 for standard care. Similarly, using the same threshold value, the probability of lifestyle advice being a cost effective intervention for avoiding an infant suffering from moderate to severe RDS would be 0.64 compared to 0.37 for standard care group. In terms of changes in QoL, the combined treatment and time effects were not significantly different between two groups.

Estimating the impact of sugar-sweetened beverage price increases and educational messages on beverage purchasing behaviour by socioeconomic position: a discrete choice experiment
Authors: Miranda Blake;  Emily Lancsar; Kathryn Backholer; Anna Peeters

Price increases on sugar sweetened beverages (SSBs) feature prominently in the suite of recommended regulatory approaches to address population weight gain. The impact of price increases on socioeconomic inequalities in SSB consumption remains uncertain. This study was undertaken to examine the predicted impact of altered beverage prices and educational messages on consumer purchasing behaviour choice and their differential effect by socioeconomic position. A discrete choice experiment (DCE) was conducted with 2098 adults representative of the Australian population. An orthogonal design was generated such that each subject completed 20 hypothetical choice scenarios in a convenience store setting. The DCE was developed and refined based on literature search and focus group (n=24) and pilot study (n=160) findings. A labelled experimental design was used with seven SSB and non-SSB options (energy drink, regular soft drink, diet soft drink, fruit juice, bottled water, plain low-fat milk, flavoured milk) described by two attributes:  four alternative-specific price levels and four generic volume levels. In each scenario, subjects were instructed to select which of seven beverage options (or no beverage) they would choose. Immediately prior to beginning the choice sets, half of participants were randomly presented with a real-world point-of-sale educational poster designed to discourage SSB selection. Our analysis explores both observed and unobserved heterogeneity in preferences and scale using mixed logit, clogithet and generalized multinomial logit models. Respondent trade-offs across attributes are investigated via marginal rates of substitution.  Predicted probability analysis is undertaken to explore predicted beverage purchases under a number of policy relevant scenarios. Predicted purchase results are used to calculate own and cross-price elasticities by education and income categories. Results are expected to inform public education strategies aimed at decreasing SSB consumption at population or subgroup levels for more effective and equitable health outcomes.

Placing a value on avoiding cancer recurrence: women's preferences for contralateral prophylactic mastectomy
Richard De Abreu Lourenco; Marion Haas; Jane Hall; Kim Parish; Domini Stuart; Rosalie Viney<./div>

We investigated women’s preferences for routine monitoring or contralateral prophylactic mastectomy (CPM) to manage breast cancer recurrence risk.

A community based discrete choice experiment (DCE) was used with attributes and levels derived from qualitative research with women who had undergone treatment for early stage breast cancer. The DCE presented women with 12 choices that described the underlying characteristics of routine monitoring and CPM: mode and frequency of monitoring; risk of cancer recurrence; risk of pain or loss of breast sensitivity; involvement in decision making; and costs. For each question, women were asked to choose their preferred management option. Women also rated their degree of concern about each of the attributes, including cancer recurrence, when making their choices. Results were analysed using mixed logit and latent class analysis, and expressed as marginal willingness to pay (mWTP). Results: 57.5% of women always chose one option, typically routine monitoring (49.1%), with fewer always choosing CPM (8.4%). Women fell into three groups: those preferring routine monitoring; those preferring CPM; and those who were willing to trade between the options (‘traders’). Among traders, choices were most highly influenced by the risk of cancer recurrence; women were less likely to choose an option associated with higher risk. Women were more likely to choose options associated with less intrusive methods of monitoring and where they were involved in decisions about their care. Women who were concerned about cancer recurrence were more likely to choose CPM over routine monitoring, and had a higher mWTP associated with avoiding cancer recurrence. Conclusions: Women have strong preferences regarding choice of management for breast cancer recurrence that reflect their concerns about the health effects of ongoing management and the associated experience of care.

Persistent healthcare costs: an analysis of persistently high healthcare costs in the short term and long term
Thomas Longden; Chun Yee Wong; Phil Haywood; Jane Hall; Kees van Gool

Individual healthcare costs have a highly skewed distribution (Jones, Lomas et al. 2015) but also contain a large random component that means that it is rarely the same people driving the bulk of health expenditures (Ash, Zhao et al. 2001). While some people do have persistently high healthcare costs, many individuals move in and out of high cost categories and the healthcare system itself (Ronksley, McKay et al. 2015). Understanding the persistence of high and low costs of healthcare will be important for understanding the dynamics of cost distributions over time and forecasting how costs will change in coming years. Managing high costs of healthcare can only occur once the health status of those who fall into these groups is understood. To contribute to the debate on the stability of the distribution of healthcare costs we focus on administrative data for over 250,000 Australians from 2006 to 2014 and investigate the health states related to persistently high healthcare costs. We analyse the nature of persistent health costs by focusing on high cost groupings for a range of costs (specifically primary care, hospital, pharmaceutical and total health care costs) and assess whether the incidence of persistent high costs is driven by diagnoses, the complexity of a patient’s morbidity, the type of healthcare provided and the time to death. The approach we apply utilises maximum likelihood estimation of endogenous switching regression models and allows us to separately review the drivers of costs for those patients that do and do not have persistently high/low costs. Using decile groups for each individual year allows us to focus on persistence in the cost of healthcare in the short term (persistence for two consecutive years) and long term (persistence for three years or more).

The Mortality Effects of Retirement: Evidence from Social Security Eligibility at Age 62
Maria Fitzpatrick; Timothy Moore

Social Security eligibility begins at age 62, and approximately one third of Americans immediately claim benefits upon reaching that age. We study the link between retirement and health by examining whether mortality changes discontinuously at this threshold. Using mortality data that covers the entire U.S. population and includes exact dates of birth and death, we document a robust two percent increase in overall male mortality immediately after age 62. The rise in mortality is closely connected to changes in labor force participation, implying that mortality increases by approximately 20 percent among those who stop working because Social Security is available.

Maturation and Risky Behaviors
Eric Mak; Angela Mak

Lack of self-control before maturation is a popular explanation of adolescent risky behaviors: adolescents gain self-control as they mature, causing them to moderate their behaviors. Even though its policy applications are plenty, this explanation lacks empirical support because maturation is not observed in behavioral data. To that end, I consider maturation as a treatment both its timing and treatment effect being unknown. I show its identification under a standard difference-in-difference setting, then proceed to estimate the corresponding econometric model. Based on the National Longitudinal Survey of Youth 1997, the estimated maturation age distributions for males and females both peak at age 21, matching neuroscientific estimates on brain maturation. The estimated maturation gradient for binge drinking (10$\%$) is greater than the policy effect of legal drinking age (6$\%$), thereby lending a natural benchmark for the latter.

Has consumer directed care improved the quality of life of older Australians? An empirical assessment incorporating the EQ-5D-5L and the ICECAP-O instruments
Norma B. Bulamu; Billingsley Kaambwa; Emily Lancsar; Liz Gill; Ian Cameron; Julie Ratcliffe

Aims: The Australian Federal Government has recently committed to major policy reform in aged care, commencing with the introduction of consumer directed care (CDC) across the community aged care sector. The aims of this study were to assess the impact of CDC on the quality of life of older Australians and to determine the extent of variation in quality of life according to the length of exposure to CDC.
Methods: Quality of life was assessed using the EuroQoL 5 dimensions 5 level (EQ-5D-5L) and the older people specific capability index (ICECAP-O). The relationships between quality of life, length of time receiving CDC and socio-demographic characteristics were examined using descriptive statistical and multivariate regression analyses.
Results: In total 484 older people were approached of whom 150 (31%) consented to participate. Mean quality of life score were 0.56 (sd=0.26) and 0.76 (sd=0.17) according to the EQ-5D-5L and the ICECAP-O respectively. Sub-group analyses revealed higher quality of life scores for those in receipt of CDC for 12 months [0.54 (0.25) and 0.72 (0.18)], although these differences were not statistically significant. Multivariate analysis indicated that age (p=0.001) and hours of support (p=0.001) were associated with higher quality of life for the EQ-5D-5L whilst living alone (p=0.013) and hours of support (p=0.015) were associated with higher quality of life for the ICECAP-O.
Conclusion: Although little variation was found overall in quality of life outcomes according to the length of exposure to CDC for either the EQ-5D-5L or ICECAP-O, those with a longer period of exposure indicated a stronger capability in being able to do things that made them feel valued. Longitudinal follow up is needed to facilitate a detailed examination of the relationship between CDC and its longer term influences on quality of life.

Does School Starting Age Matter? The Impact of School on Childhood Obesity, Time Use and Diet in Australia
Ho-Ching (Angela) Mak

Childhood obesity has an alarming upward trend across the world. This paper studies the impact of school on childhood obesity in Australia. My study is the first to investigate also how school entry affects diet and time use of children, which are considered as factors associated with weight outcomes. Using school entry rules in different Australian states and territories, a fuzzy regression discontinuity design is implemented to estimate the causal impact of school on the above outcomes. A positive and significant impact is found on the probability of being obese, and the probability of having a waist-to-height ratio exceeding 0.5. Children who enter school early are more likely to consume sugary drinks. No significant impact is found on total exercise time as parental time is substituted by the time at school.

The prevalence and determinants of non-communicable diseases in China: evidence from China Family Panel Study in 2010 and 2012
AuthorsL Tianxin Pan

In the past 65 years, China has undergone significant demographic change induced by an ageing population and increasing life expectancy at birth. Mass urbanization and greater wealth have brought changes in lifestyles in both urban and rural areas. These demographic and socioeconomic changes have resulted in a shift in the disease burden from communicable diseases to non-communicable diseases (NCDs). There is enormous, and yet hitherto fully accounted, growth in the population living with NCDs. Evidence has documented the prevalence of chronic diseases as a whole, which includes both chronic infectious and non-communicable diseases, and some specific NCDs, based on national and sub-national household survey. However, little is known about the national-wide NCDs prevalence and risk factors.  This paper proposes to fill this gap by providing a comprehensive analysis of the prevalence, distribution and determinants of NCDs in China. This paper will use data from China Family Panel Study (CFPS), a high-quality nationally representative, biennial longitudinal survey designed to collect individual-, family-, and community-level data. This research will use the two current available waves of the data from 2010 and 2012 and pooled probit and fixed effects regression models to estimate the association between the probability of NCDs and key risk factors. This research will have important implications for understanding the burden of disease and development of policies to curb the growth of NCDs across the Chinese population.

Endogenous estimation of waiting list dynamics at the patient level
Daniela Bond-Smith

The key challenge in predicting patient waiting times for hospital admission is estimating the dynamic effect of changes in the composition of the waiting list, both from other patients waiting concurrently and from the path-dependent effect of historical changes. A clear shortcoming of previous research is that the proposed models are unable to directly capture the dynamic feedback effects characteristic for hospital waiting lists, because cross-sectional independence is assumed. We propose a model of waiting time that characterises the dynamic interaction at the patient level. A particular strength of our approach is that we can demonstrate its rationale based on routinely collected patient records. To achieve this, we conceptualise the waiting list as a two-dimensional space. This patient space is captured in a weights matrix that is estimated jointly with the underlying model. To do this, we first calculate a local spatial autocorrelation statistic to obtain an empirical weights matrix and then estimate the model using an asymptotically optimal IV estimator for cross-sectionally dependent data. We also present the dynamic equilibrium effects illustrating the patient-specific impact of changes in demand or supply factors including all dynamic feedback effects. To illustrate the relevance of this model, we analyse the impact of the introduction of a hypoplastic left heart syndrome surgery program at the Sydney Children’s Hospital Network on waiting times for other patients requiring intensive care facilities. The suggested model has clear advantages in terms of its theoretical consistency and explanatory power over the existing literature. It provides additional, clinically relevant information and may be useful in guiding treatment planning and clinical evaluation decisions. The paper is original in its application of spatial econometric estimation approaches to a non-spatial application in public health. Hence, it also illustrates the ample possibilities for other applications of this method.

Anomalous billing by health care providers: Evidence from a retrospective analysis of anesthesia cases
Eric Sun; Anupam B Jena; Richard P Dutton

In the United States, physicians exercise tremendous discretion in choosing billing details that determine payment for their services.  While understanding the degree to which physicians inappropriately use this discretion has implications for setting payment policies, separating inappropriate discretion from actual differences in patient complexity can be empirically challenging.  Anesthesia offers a useful test case because practitioners are compensated by self-reported length of time (“anesthesia time”) spent on a case, so that anomalous patterns in a practitioner’s reported times—such as an excess number of cases with an anesthesia time ending in five (e.g., 65 minutes) —can be used to objectively identify instances of inappropriate billing. Using a national database of anesthesia cases, we examined the presence of anomalous billing patterns among 5,755 anesthesia providers. We found that anomalous patterns are fairly common—a substantial minority (24%) of practitioners report an unusually large number of cases with anesthesia times ending in 5 or zero.  Practitioners who were particularly anomalous—those in the top 5th percentile in terms of anesthesia times ending in 5 or zero—also tended to report anesthesia times that were 22 minutes longer than expected, which would net an additional $34 to $98 per case, depending on payer.  While inappropriate practices seem confined to a minority of anesthesia practitioners, our results provide some impetus for ongoing policy efforts aimed at reducing the amount of discretion given to physicians.


Benefit cost analysis of three skin cancer public education mass-media campaigns
Authors: Chris Doran; Rod Ling; Joshua Byrnes; Melanie Crane; Anthony Shakeshaft; Andrew Searles; Donna Perez

Public education mass media campaigns are an important intervention for influencing behaviour modifications. However, evidence on the effectiveness of such campaigns to encourage the population to reduce sun exposure is limited. This study investigates the benefits and costs of three skin cancer campaigns implemented in New South Wales from 2006-2013. This analysis uses Australian dollars (AUD) and 2010-11 as the currency and base year, respectively. Historical data on skin cancer were used to project skin cancer rates for the period 2006-2020. The expected number of skin cancer cases is derived by combining skin cancer rates, sunburn rates and relative risk of skin cancers due to sun exposure. Counterfactual estimates are based on sunburn exposure in the absence of the campaigns. Monetary values are attached to direct (treatment) and indirect (productivity) costs saved due to fewer skin cancer cases. Monetary benefits are compared with the cost of implementing the campaigns and are presented in the form of a benefit-cost ratio. Rela- tive to the counterfactual (i.e., no campaigns) there are an estimated 13,174 fewer skin can- cers and 112 averted deaths over the period 2006-2013. The net present value of these benefits is $60.17 million and the campaign cost is $15.63 million. The benefit cost ratio is 3.85, suggesting that for every $1 invested a return of $3.85 is achieved. Skin cancer public education mass media campaigns are a good investment given the likely extent to which they reduce the morbidity, mortality and economic burden of skin cancer.

Cost-effectiveness of the BRECONDA decision aid for breast reconstruction
Authors: Bonny Parkinson; Paul Brown; Kerry Sherman; John Boyages; Linda Cameron; Elisabeth Elder; Thomas Lam; Laura-Kate Shaw

Introduction: The decision to have breast reconstruction following a mastectomy is a ‘preference sensitive’ decision that should incorporate a patient’s values, attitudes and preferences. A recent study, the Breast RECONstruction Decision Aid (BRECONDA) study, assessed the impact of an online patient decision aid (PtDA) to assist women faced with having to decide whether or not to have breast reconstruction surgery, finding that women using the decision aid experienced significantly less decisional conflict than women receiving standard care. The purpose of this study is to examine the cost effectiveness of the BRECONDA PtDA compared to no PtDA for Australian women with breast cancer. Methods: Health services usage and quality of life measures were collected for 222 women (106 in control condition, 116 in treatment) as part of the BRECONDA study. Outcome measures were difference in utility scores, as measured by the EURO-QOL 5D, the extent to which these correlate with the traditional measures of effectiveness such as decisional regret, satisfaction, and decisional conflict. Cost comparisons were based on health services usage (e.g., hopsitalizations, outpatient visits, and GP visits) and cost of the PtDA. Results: The results suggest no differences in cost of services or EURO-QOL 5D. However, the differences in decision regret and decision conflict suggest that the PtDA was valued by women, and raises questions about the appropriateness of traditional measures of outcome evaluation used to evaluate PtDA. Conclusions: The study concludes with recommendations for behavioural medicine researchers on the appropriate way to assess the cost effectiveness of PtDAs.

The replacement cost of informal care for people with mental illness in Australia
Authors: Yong Yi Lee; Sandra Diminic; Emily Hielscher; Meredith Harris; Jan Kealton; Harvey Whiteford

Introduction Informal carers play a significant role in providing ongoing support and assistance to people with mental illness. This study estimated the value of informal care delivered by Australian mental health carers, in terms of the estimated cost to ‘replace’ this care by formal health services. Methods We calculated the replacement cost of informal mental health care in Australia by: (1) estimating the total number of mental health carers aged 15+ years in Australia; (2) estimating the total annual hours of care provided by mental health carers for different tasks – i.e., emotional support, support for practical tasks and support for activities of daily living; (3) valuing the cost per hour to replace informal care tasks with formal services; and (4) offsetting existing government expenditure on carers. A government funder perspective was adopted to calculate replacement cost estimates for the year 2015. Input data were sourced from published data, analyses of several population surveys and a purpose-designed online survey of carers. Uncertainty was propagated from input data to final replacement cost estimates using Monte Carlo simulation. Results We estimated there were 240,000 (95% Uncertainty Interval: 220,000-260,000) mental health carers in Australia during 2015. Overall, these carers provided 208 million hours (95% UI: 181-237) of informal care per year. The majority of care involved emotional support (68%), while the remainder involved support for practical tasks (29%) and activities of daily living (3%). After adjusting for cost offsets, the total annual replacement cost was calculated to be $13.2 billion (95% UI: 11.3-15.3). Discussion Current government policies in Australia favour informal carers of people with physical health conditions. This study highlights the unique role taken on by informal carers of people with mental illness. The unique circumstances of mental health carers should be accounted for when developing future government policies for all informal carers.

The stress of parenting: Mental Health and Time Utilisation by Employed Parents in Australia
Nataliya Ilyushina

This is an innovative paper that combines research on time use and, mental health, to answer the question; how is a parents’ psychological well-being associated with the way they utilise their time. In addition, the paper investigates whether this association has gendered in nature. To tackle this question the study uses the Household, Income and Labour Dynamics in Australia Survey (HILDA). The results of the regression estimations using information on the time spent in six different activities, reveal, that household errands, but not housework are negatively associated with mental health of both mothers and fathers. Moreover, even though some activities such as errands, taking care of children and outdoor tasks have the same pattern for both sexes; only fathers’ labour hours are significantly associated with mental health, consistent with gender role theories, that suggest that a mother’s key role within a family is parenting children, while a father’s gender-based role is a breadwinner.

Does social capital support health in widowhood?
Claryn Kung

The aim of this paper is to examine how health and health behaviours change in widowhood, and whether more favourable profiles are observed for individuals with higher social capital. The Household, Income and Labour Dynamics in Australia Survey contains rich panel data on health and social capital for over 600 individuals whose partners died within the survey follow-up period. Death data are also linked to the National Death Index, allowing a rigorous analysis of the role of social capital in the health effects of widowhood over time. Fixed-effects models reveal poorer mental health among both genders and for all levels of pre-widowhood social capital, particularly in the first two years of widowhood. Short-term improvements in physical health are seen among those with lower capital, possibly due to relief from caregiver burden. Males with lower capital show lasting lifestyle changes pertaining to smoking, drinking, and exercising in widowhood. Results suggest that social capital does little to mitigate grieving or temporary dips in mental health experienced after spousal death, but among males social capital may facilitate good health behaviours in widowhood.

Socioeconomic inequality in postnatal mental health and beyond
Author: Jemimah Ride

Inequalities in mental health around the time of having a baby are of importance as mental health problems are common in this period, it is a time of heightened contact with health services (and therefore presents opportunities for intervention) and children’s development may be particularly sensitive to mothers’ mental health at this time. Previous studies have demonstrated the presence of socioeconomic inequalities in postnatal mental health, but have not used methods that utilise data on the full range of the income spectrum, such as the concentration index, nor decomposed inequality into components that may be contributing to observed inequality. This study explores socioeconomic inequality in women’s postnatal mental health using UK panel data from the Millennium Cohort Study. In addition, the longitudinal nature of the data is exploited to investigate how mothers’ postnatal mental health is associated with inequality in later mental health, as well as intergenerational implications in association with children’s outcomes. Inequality is explored using Oaxaca-type decomposition and regression-based decomposition of the concentration index, the results of which may suggest avenues warranting further investigation for reduction of socioeconomic health inequalities.

Relative Health service utilisation of Indigenous and non-Indigenous Australians at high risk of Cardiovascular Disease
Authors: Blake Angell; Tom Lung; Tracey Laba; Sandra Eades; Steve Jan

Background – Ensuring access to appropriate primary healthcare services is vital to close the gap in health standards between Indigenous and non-Indigenous Australians. This study investigates the relative utilisation of healthcare services of Indigenous and non-Indigenous Australians at high risk of Cardiovascular Disease (CVD) and examines the factors associated with use across the two groups controlling for the individual risk facing each patient.
Methods – Data was collected during the Kanyini Gap randomised controlled trial testing the efficacy of the use of a polypill to treat and prevent CVD in a high-risk population of Indigenous and non-Indigenous Australians in urban, regional and remote settings across Australia. Service use was estimated using the average Medicare Benefits Schedule (MBS) expenditure per year for each patient.
Findings- a total of 535 individuals were included in the analysis of which 51% identified as Indigenous. While Indigenous individuals had a lower MBS spend on average, this difference was not significant when individual risk and socio-demographic variables were controlled for (p=0.12). However, Indigenous individuals living in regional or remote areas had significantly lower expenditure than other individuals.

HOMELESSNESS: an innovative response
Authors: Irina Kinchin; Susan Jacups; Gary Hunter; Bernadette Rogerson

Homelessness is a complex phenomenon: it is not mere absence of secure housing, sometimes it is the cause of a range of life factors such as violence, abuse, poverty, health, social and emotional conditions, and poor employment outcomes; and sometimes homelessness is the financial inability to travel home.
An increase in the number of Indigenous homeless persons in Cairns, prompted the Queensland Police Service (QPS) to commence a pilot ‘Return to Country’ (R2C) program. The program is designed to assist homeless people who are voluntarily seeking to return to their home communities, but, for multiple reasons, could not afford to. This study assesses the costs of running the program and evaluates its net economic impact. Retrospective uncontrolled cost, cost-effectiveness and cost-offset analyses were undertaken from a societal perspective. All costs were expressed in 2014 AU$.
QPS assisted 140 individuals who wished to return home, reducing the prevalence of homelessness in the regional center by 9.6%. The total program cost was estimated as AU$ 135,831 or AU$ 970 per participant. In comparison, evidence suggested that a homeless person could cost the government an extra AU$ 5,270 – 33,508 per person/year as a result of greater utilization of health and justice services. The R2C program offers an innovative solution to Indigenous homelessness and represents a cost-effective use of public resources. This relatively simple, minimal cost program aimed at reducing homelessness potentially saved AU$ 2,714,460, not to mention psychological wellbeing and social cohesion that benefited participants and their communities.

The economic burden of Indigenous health inequality in the Northern Territory
Authors: Yuejen Zhao, Northern Territory Department of Health; Ram Vemuri, Charles Darwin University; Dinesh Arya, Northern Territory Department of Health

Indigenous health inequality is a major public health concern in the Northern Territory (NT). Indigenous Territorians constitute about 27% of the total population. This study aims to estimate the costs associated with the Indigenous health inequality in the NT between 2009 and 2013.
The Census and burden of disease data were used to estimate the costs of the health inequality by adapting the cost-of-illness approach to cost estimation. The excess cost of the Indigenous health inequality totalled approximately $16.7 billion for the 5-year period, of which 22% was due to higher health expenditure, 35% attributable to lost productivity and 43% to lost life-years. This was equivalent to an overwhelming 19% of the total gross state product in the NT.
It is proposed that the health sector must develop strategies to improve health and reduce costs due to Indigenous health inequality. The findings also highlight a need for better housing, education and employment for Indigenous people. Successful implementation of these strategies is likely to require improving cost-effectiveness of government services by combating discrimination, developing local economies, overcoming poverty and remoteness.

The causal relationship between education and health literacy
Authors: David Johnston; Rachel Knott; Michael Shields

The education-health gradient is one of the most established associations in social science. Yet despite the abundance of empirical evidence documenting the existence of the relationship, we still do not have a complete understanding of why the association exists. In particular, we do not have a clear sense of exactly what it is about education that leads to better health. The current paper attempts to uncover a part of this question by examining the causal impact of education on health literacy. Using data from the English Longitudinal Study of Ageing (ELSA) survey, we examine whether exogenous changes in compulsory schooling reforms of the 1940s and 1970s – which raised the minimum age at which individuals in the UK could legally leave school, impacted the ability of older respondents to answer a series of questions relating to a fictitious medicine label. Preliminary results suggest that there is a causal relationship between education and health literacy for females. This could have serious implications for policy – particularly given the large proportion of respondents with lower education that had been advised by their doctor to follow therapy regimes to manage chronic health conditions.

College Spouse, Healthy Life
Authors: Elena Capatina; Xiaodong Fan

It is well known that married individuals are healthier than singles. While selection into marriage has been found to contribute to this relationship, current evidence suggests there is a also a significant protective role of marriage on health. In this paper, we study in detail this protective role of marriage. In particular, we explore how health transitions are affected by spousal characteristics that include age, education, physical and mental health status, cognition, labor force status, and employer provided health insurance status. We also explore how health behaviors are affected by these spousal characteristics. We study these effects separately for men and women using the HRS.

The causal effect of education on health and health-related behaviours: what can the Australian twins data tell us?
Author: Jinhu Li

The empirical literature that aims to identify the causal effect of education on health often exploits the enactment of schooling laws as a source of exogenous variation in education. The external validity is problematic as the estimated local average treatment effects (LATE) represent the effects around the change in education level affected by the specific schooling law. This study aims to exploit the variation in education among identical twins to identify the causal effect of education on health and health behaviours. Estimates from a twin design will be closer to the average treatment effect (ATE) as within-twins differences can range across much wider education levels. A twins-fixed effects model is used as the main regression model. I conduct sensitivity analyses to test whether other differences in twins other than genes and their common social environment can cause further endogeneity bias. I test how sensitive the main results are when only including twins who had similar early-life circumstances in the analysis. To test reverse causality I check whether the main results are sensitive when birth weight differences and other early life health differences between identical twins are included in the analysis. I use data from the 2014 Australian Twins Registry (ATR) Adult Health and Lifestyle Questionnaire. The final study sample includes 959 pairs of identical twins and 349 pairs of non-identical twins. Preliminary results show that having a bachelor degree has a positive effect on self-assessed health, reduces the probability of ever smoking in life and reduces the amount of cigarette consumption. Completing high school doesn’t have any statistically significant effect on health and health behaviours. Once early life health is controlled for, the effect of having a bachelor degree becomes insignificant except for the probability of ever smoking and the amount of cigarette consumption.

Parent-children mental health interaction
Authors: Do Won Kwak, Myra Yazbeck, Xin Li, Kam Ki Tang, Prasada Rao

Mental health problems can exert considerable negative impacts on the sufferers themselves, as well as their friends and family members, their communities and society as a whole. The objective is this paper is to investigate the interdependence of mental health status among close family members. Given that the effects could be realized over many years we do not study mental health in a static situation, but instead, study the mental health dynamic. We also study the mechanisms behind mental health shock transmission. Our results suggest that mothers’ mental health has positive and significant impacts on adolescents’ mental health, even after controlling for a comprehensive group of individual, household, and community and area characteristics. Furthermore, we observe gender differences in this effect, with mother-daughter mental health interactions found to be stronger than interactions between father-daughter, mother-son and father-son. Also, mothers with higher education levels tend to have a greater influence on their children’s mental health status. This suggests that parenting quality is a possible mechanism behind the mother-child mental health interdependence.

Beyond expectations: rotavirus vaccination program is likely cost-saving in Australia
Josephine Reyes; James Wood; Philippe Beutels; Kristine Macartney; Peter McIntyre; Robert Menzies; Nicole Mealing; Anthony Newall

Background Universal vaccination against rotavirus was included in the funded Australian National Immunisation Program in July 2007. Predictive cost-effectiveness models were used to assess the program before introduction. Since implementation, a range of empirical data relevant to measurement of real-world program impact has become available allowing improved estimation of the value for money achieved.

Methods We conducted a retrospective economic evaluation using population level post-implementation data on vaccine uptake, before-after measures of program impact and published estimates of excess intussusception cases. These data were used as inputs into a multi-cohort compartmental model which assigned cost and quality of life estimates to relevant health states. A healthcare payer perspective was adopted, with the primary outcome being the discounted cost per quality adjusted life year gained. We reported results including or excluding unspecified acute gastroenteritis (AGE) hospitalisations. Results Relative to the baseline period (1997-2006), we estimated that ~77,000 hospitalisations (17,000 coded rotavirus and 60,000 unspecified AGE) and ~3 deaths were prevented and an estimated excess of 78 cases of intussusception occurred over the 6 years (2007-2012) after implementation of the rotavirus program. Approximately 90% of hospitalisations prevented were in children

Mapping CHU9D utility scores from the PedsQL
Christine Mpundu-Kaambwa; Gang Chen; Ray Russo; Katherine Stevens; Karin Dam Petersen; Julie Ratcliffe


Purpose: The PedsQLâ„¢ 4.0 Short Form 15 Generic Core Scales (hereafter the PedsQL) and the Child Health Utility 9 Dimension (CHU9D) are two generic instruments designed to measure health-related quality of life in children and adolescents in the general population and paediatric patient groups living with specific health conditions. Although the PedsQL is widely used among paediatric patient populations, presently it is not suitable for the calculation of quality adjusted life years (QALYs) for application in economic evaluation because it produces summary scores which are not preference-based. This paper examines different econometric mapping techniques for estimating CHU9D utility scores from the PedsQL for the purpose of calculating QALYs for cost-utility analysis.

Methods: The PedsQL and the CHU9D were completed by a community sample of 755 Australian adolescents aged 15-17 years. Five regression models were estimated: ordinary least squares estimator, generalised linear model, robust MM-estimator, multivariate factorial polynomial estimator and beta-binomial estimator. The mean absolute error (MAE) and the mean squared error (MSE) were used to assess predictive ability of the models.

Results: The MM-estimator with stepwise-selected PedsQL dimension scores as explanatory variables had the best predictive accuracy using MAE and the equivalent beta-binomial model had the best predictive accuracy using MSE.

Conclusions: The preferred mapping algorithm (MM dimension-level models) can be used to predict CHU9D utilities from the PedsQL with a high level of accuracy. The algorithm facilitates the estimation of health state utilities for use within economic evaluations in paediatric populations where only PedsQL data is available.

The effects of health on occupation: Evidence from the HILDA survey
Joanne Flavel

Maintaining individuals with health limitations in the labour force is a challenge of increasing importance given the ageing population. The literature has established that poor health is strongly associated with a lower likelihood of labour force participation but the evidence on employment outcomes other than labour supply decisions is limited in comparison. Determining the effect of health on occupation may tell us how people adapt to their limitations and what types of jobs make this harder or easier. This paper uses dynamic multilevel modelling to examine the effect of health and changes in health on occupation for the working age population. Two measures of occupation are used to capture two aspects of occupation highlighted in the literature as linked with health: physical job demands and status. The models use data from the first fourteen waves of the Household, Income and Labour Dynamics in Australia Survey (HILDA) and accounts for initial condition, state dependence and unobserved heterogeneity. The results of the analyses find some evidence that a health shock reduces the likelihood of manual employment for men. There is no significant effect of health, health shocks (for women) or health improvement on occupation or occupational status after controlling for selection into employment.

A Dynamic Analysis of Chinese Disabled Older People and Disable Free Life Expectancy from 2000-2010
Bei Lu, Mingxu Yang, Hong Mi and Xiaoting Liu

Objective: To explore the dynamic changes of disability prevalence and related impact factors in China from 2000 to 2010, and to discuss the disability free life expectancy trend over this period.

Method: Three waves data of Sample Survey of the Aged Population in Urban/Rural China (SSAPUR) were used. The Logistic Regression Models for each wave, the Random Effect model for three waves were employed to identify predictors. The projection of Disability Free Life Expectancy was estimated by Sullivan’s method.

Results: There was a decline in ADLs prevalence from 8.92% to 8.13% in the 10- year period, which was predicted from urbanization, improvement in socio-economic status and increasing medical insurance. The health life expectancy increased, while the duration of disability experienced a high “compression of morbidity” stage from 2000 to 2006 and seemed turn to “expansion” from 2006 to 2010.

Discussion: Long term care policy and service should give priority to the disadvantaged elderly persons with disability, especially in the rural areas.

Cost-effectiveness Analysis of Nasal High Flow versus Nasal CPAP as Primary Respiratory Support for Preterm Infants
Li Huang; Brett Manley; Calum Roberts; Louise Owen; Peter Davis; Kim Dalziel

Background: Nasal High Flow and nasal CPAP are the two most common non-invasive modes of respiratory support for preterm infants with early respiratory distress. Knowledge regarding the cost-effectiveness of the two therapies is lacking.

Methods: We conducted an economic evaluation of High Flow and CPAP therapy alongside a multicenter, randomized controlled trial targeting High Flow and CPAP as primary support for preterm infants with respiratory distress. The inpatient costs incurred in all participating Australian sites were linked to the trial database. The cost-effectiveness of the two therapies was analyzed from a health system perspective.

Results: The total cost of hospital stay per infant was non-significantly higher in the CPAP group $32,036 (95% CI $28,082, $35,989) compared to the High Flow group $29,785 (95% CI $26,332, $33,239), P=0.40, as was the cost of the treatment-specific disposable equipment ($135 and $118 respectively, P=0.15). CPAP was more effective in preventing treatment failure within 72 hours of randomization, less effective in avoiding nasal trauma, and neither statistically or economically different from High Flow in preventing intubation and ventilation. An incremental cost-effectiveness ratio was estimated of $20,623 (95% CI -$25,583, $145,237) per additional treatment failure avoided if CPAP was used compared to High Flow.

Conclusions: CPAP was more effective than High Flow in preventing treatment failure at a greater average cost and may be cost-effective. Whilst High Flow was not cost-effective compared to CPAP in this trial, given its lower average cost, similar intubation and ventilation rates and lower nasal trauma rates, future research to investigate its alternative place in the treatment algorithm may be warranted.

Migration and Subjective Wellbeing in Australian Aged Care Workforce
Author: Henry Cutler

In Australia the population of care workers increased by 36 per cent from 131,283 in 2006 to 178,340 in 2011. It is predicted that the number of aged care workers needed will triple over the next quarter of a century. However, there was increasing difficulty to filling vacancies for registered aged care nurses, with nearly 40 per cent of vacancies taking more than a month to fill. It is timely to have a deeper understanding of the current aged care workforce, which is comprised of highly professional workforce and lower skilled workers. Immigrants currently make up about 35% of the aged care workforce – a proportion that has increased markedly over the past decade. We use the linked employer-employee data from the 2012 National Aged Care Workforce Census and Survey (NACWCS) to examine the relationship between immigration and different domains of subjective wellbeing in the aged care sector. Since aged care employees were nested in aged care facilities, the NACWCS data are clustered. Therefore, the standard assumption of independent observations is unlikely to hold due to the dependence among surveyed employees within the same facility, as well as the dependence among facilities in the same state. In this paper we apply a two-level random-effects model to take into account that employee characteristics may interact with facility characteristics and state-level institutional characteristics.

The supply response to hospital emergency department waiting times: Evidence from a flu pandemic
Peter Sivey; Anna Burgess; Anne-Maree Kelly; Hassan Vally

Hospital emergency departments (EDs) ration access to care under excess demand using a combination of prioritisation mechanisms and waiting times. Waiting times reduce demand for care by increasing the opportunity cost to patients of seeking treatment, leading to a downwards-sloping demand curve. However increased waiting times may also provide incentives to providers to increase the quantity or speed of treatments, leading to an upwards-sloping supply curve. Upwards-sloping supply may occur for two reasons: Firstly, hospitals may face performance incentives which reward shorter waiting times. Secondly, hospitals may be altruistic towards their patients and prefer to reduce the waiting time each patient faces.

We test for the existence of an upwards sloping supply curve in Victorian hospital EDs by exploiting a shock to demand caused by the ‘swine flu’ pandemic of May 2009. We use unit-record patient data aggregated to the hospital/day level to estimate panel data models of the relationship between waiting times, the number of patients treated, and the average ‘treatment time’ for each patient. Our rich data will allow us to account for changes in the characteristics of patients including diagnosis, triage category, mode of arrival, and demographics. Our models allow us to take account of unobserved heterogeneity at the hospital level and isolate variation in waiting times caused by an exogenous shock.

Our results will help policymakers to understand how hospital EDs respond to demand shocks, balancing the treatment needs of patients and the imperative to keep waiting times down. They will also help contribute to the nascent literature in modelling the economic incentives in hospital EDs more generally.

Reforms, scale and scope economies and the English NHS
Renata Kosova; Giorgia Marini; Marisa Miraldo; Mujaheed Shaikh

In this paper we assess whether giving greater financial and operational independence to hospitals improves performance by means of increased economies of scale and scope. We apply a difference-in-differences strategy to a sample of English NHS trusts for the period 2000 to 2008 following the foundation trust (FT) policy implemented in 2004. FT hospitals were given greater autonomy in development of businesses and strategies that best coordinated their financial and operational structure with local needs. We expect that under new financial and managerial freedoms, FTs will invest mainly in services where they are able to extract economies of scale and scope, with a consequent cost advantage for FTs with respect to NHS trusts that cannot benefit from such flexibility. A way to verify the existence of such opportunistic behavior is to test whether there are any differences in the cost structure of FTs and NHS trusts, following the implementation of the FT policy which has made FTs more likely than NHS trusts to exploit economies of scale and scope in the take-up of the whole reform agenda. We find that the FT status discourages economies of scale, but facilitates scope economies. However, we also find that regardless of status, hospitals in general exhibit economies of scale and diseconomies of scope. Analysis by type of services provided (day case, elective, non-elective care) provides interesting insights as well.

Competition in the market for medical specialists
Hugh Gravelle; Matthew McGrail; Susan J. Méndez; Anthony Scott; Jongsay Yong

Despite an increasing number of new specialists doctors entering the workforce and the high concentration in their market (over 85% of all specialists are located in major cities), bulk billing rates for services provided by specialists are very low (only 30%). Various reasons contribute to high prices, for instance medical specialists in Australia provide services in a market where prices are unregulated; they are more likely to operate their private rooms adjacent to hospitals or in affluent areas, where patients tend to have additional private insurance coverage; and patient’s preferences for prices, waiting times and quality of care may be less important in this market because they often rely on their GPs’ referral when seeing a specialist. GPs acting as gatekeepers create entry barriers for new specialists that contribute to an increase in market power.

The aim of this research is to investigate the determinants of prices charged and bulk-billing rates provided by medical specialists in Australia. We discuss and examine empirically some aspects of competition between specialists, including densities of other specialists and GPs in small areas, distances between GPs and specialists, and between specialists in the same specialty, and also examine referral networks proxied by medical school graduation cohorts. We use detailed individual doctor level panel data on a representative sample of around 4,000 medical specialists from the Medicine in Australia: Balancing Employment and Life (MABEL) survey.

Under- and over-use of coronary angiography for acute myocardial infraction and stable ischaemic heart disease
Jongsay Yong, Sara Vogrin, Jodie L Burchell, Anthony Scott, Richard Harper, Vijaya Sundararajan

Angiography is a diagnostic procedure using a special dye and x-rays to examine blood flows through the arteries. Current clinical guidelines recommend that all acute myocardial infarction (AMI) patients receive angiography prior to discharge. For stable ischaemic heart disease (sIHD), angiography is only recommended for patients with a high pre-test likelihood of obstructive coronary artery disease, and then only following positive non-invasive testing. Despite guideline recommendations, there are concerns of significant overuse of angiography for sIHD patients and under-use for AMI patients. This paper uses hospital administrative data from Victoria from 2000/01 to 2012/13 to identify and document, by hospital and over time, the extent of over- and under-use of angiography for respectively sIHD and AMI patients. The paper examines the variation in angiography rates for the two types of inappropriate care across hospitals and links the observed variation to institutional factors such as private hospital status and constraints on catheterization laboratory capacity. Preliminary computation using 2011/12 data shows that about 4,000 AMI patients were not given angiography but should have, while more than 4,500 stable IHD patients received angiography but should not have. There is an obvious mis-allocation of resources—lives could be saved while costs to the health system could be reduced if more AMI patients could receive angiography in place of sIHD patients.

Using a Discrete Choice Experiment to elicit consumer preferences for residential aged care services
Rachel Milte; Julie Ratcliffe; Gang Chen; Maria Crotty

There are few studies of the preferences of consumers for aged care services, such as residential care. Therefore, while there is information available on general satisfaction with residential care, there is limited empirical knowledge on which characteristics of a residential care facility are the most or least attractive to people living in residential care and their family members or the general population. The aim of this study was to utilise a discrete choice experiment (DCE) methodology to determine the preferences of people living in residential care, their family members, and the general population for both environmental and care characteristics of long-term residential care services.

A DCE survey was administered to people living in residential care or their family members (n=545) and members of the general population (n=701). The data were analysed using a mixed logit model that takes participants’ preference heterogeneity into account. The findings indicate that all six attributes investigated were statistically significant factors for participants. Feeling at home in their own room and care staff being able to spend enough time with residents were the two most important characteristics to residents and their family members and the general population sample. Feeling at home in shared spaces, and staff being very flexible in care routines were also highly preferred by residents or their family members. Staff flexibility with care routines, and being able to spend enough time with residents, and having access to outside and gardens were highly important to general population participants. In summary, the findings indicate that preferences for nursing homes are highly influenced by the desire to preserve individuality in the physical environment; the promotion of flexibility in care routines; and workforce planning to ensure that the amount of time that care staff have to be engaged with residents is maximized.

Simon Fifer; Ana Zekan

Objectives: To investigate the key parental drivers of choice for the influenza vaccine for children in Australia, with particular focus on mode of administration (i.e. injection vs intranasal).

Methods: A sample of 828 parents provided data in November 2015, collected through an online survey using state-of-the-art choice experiments. In the survey parents were asked to trade off both injectable and intranasal influenza vaccines with different features to ascertain what is most important to them when making decisions for their child. Data were modelled using a Latent Class Model (LCM). The LCM allows for preference heterogeneity which is handled via a discrete distribution.

Results: The most important features to parents when choosing a vaccination were mode of administration, cost and doctor recommendation. Scenarios are presented for four different child age bands, with outcomes measured as a change in consumer surplus. Consumer surplus (otherwise known as Total Willingness to Pay) represents a measure of the additional benefits that an alternative brings to a market, and is often interpreted as the total value of the alternative. Consumer surplus results show that having an intranasal option available generates an additional benefit over only having an injectable option (holding everything else constant), equivalent to a weighted consumer surplus of approximately AUD$31 per child, per season.

Conclusions: The results show when it comes to choosing an influenza vaccine for their child, parents highly value an intranasal mode of administration, are very cost sensitive and are heavily influenced by doctor recommendation. This study highlights how consumer surplus can be used to measure the value of non-health outcomes. Evidence from these types of studies can be used in health technology assessment to provide measurement of patient preferences for use in decision making by regulatory / healthcare governing bodies. Supported by AstraZeneca

Policy choice in a complicated health insurance market: Do people get it right?
Nathan Kettlewell

This paper evaluates health insurance policy selection using a discrete choice experiment closely calibrated to the Australian private health insurance market. The experimental approach overcomes some limitations of revealed preference research. The results indicate that consumers are likely to make choices that violate expected utility theory, use heuristic decision strategies, and over-insure relative to minimising out-of-pocket costs. Decision quality is significantly lower when choosing a bundled hospital/ancillaries health insurance policy (compared to stand-alone ancillaries cover), which is the policy type most consumers purchase in Australia.

Consumer preferences for food processing technologies: evidence from a discrete choice experiment (DCE)
Elena Meshcheriakova; Stephen Goodall; Rosalie Viney

Objective: This study aimed to determine preferences and willingness to pay (WTP) for a range of food processing technologies.

Consumers were presented with hypothetical food choices based on different processing techniques (organic, genetically modified, irradiated, and engineered nano-technology). Evidence suggests that people favour organic food and avoid GM foods, however, little is known about attitudes towards other processing technologies. Other attributes in the DCE included shelf-life, country of origin, price, certification label and risk of foodborne illness.

Method: Online survey was completed by 1,503 respondents. Each respondent faced 16 choice sets for two products (cheese and frozen berries). The analysis was conducted using clogit, mixed logit and generalised multinomial logit models (G-MNL) to account for scale and preference heterogeneity. A best fit model was selected based on the three measures of fit (log-likelihood, AIC and BIC) and estimates of WTP were calculated.

Results: In general consumers preferred lower price, lower risk of foodborne illness and Australian produced and certified products. Most consumers viewed food processing technologies negatively, and preferred conventional and organic products. The estimated WTP in the G-MNL model showed that consumers would pay a small premium to buy organic food (under $2), and would require a price discount to accept other technologies ($3-$5). To accept food from China, respondents indicated that the product would need to be $10 cheaper than the Australian equivalent. This study demonstrates that consumers have strong preferences for the way that food is processed; however it is unclear whether consumers considered the positives aspects of food processing, such as reduced pesticide use or improved yield when making their choices.

Out of sight but not out of mind: Home countries' macroeconomic volatilities and immigrants' mental health
Ha Nguyen; Luke Connelly

While much is now known about the effects of macroeconomic conditions in the place where people live on their health, we know little about how and to what extent macroeconomic fluctuations in the place where people do not live but are, in some way, connected to, can affect their health. This paper is the first to examine the impact of macroeconomic conditions in the country of emigration on mental health of international immigrants. We use an econometrically-robust approach that exploits exogenous changes in macroeconomic conditions across immigrants’ home countries over time and controls for immigrants’ observable and unobservable characteristics. We use 12 years of data from the Household Income and Labour Dynamics in Australia panel and macroeconomic indicators for 52 countries of origin. We provide the first solid empirical evidence that better economic performances by immigrants’ countries of origin, as measured by lower CPI or higher GDP, improve immigrants’ mental health. Furthermore, the CPI effect is statistically significant and sizeable. The CPI effect also diminishes over time, suggesting that the effects on immigrants are lower the longer it is since they emigrated. By contrast, home countries’ unemployment rates and exchange rate fluctuations have no impact on immigrants’ mental health.

Regression to the mean in quasi-experimental economic evaluation: the example of total knee replaceement
Chris Schilling; Dennis Petrie; Michelle Dowsey; Peter Choong; Philip Clarke

Introduction: Many treatments are evaluated using quasi-experimental pre-post studies susceptible to regression to the mean (RTM). Ignoring RTM could bias the economic evaluation. We investigated this issue using the contemporary example of total knee replacement (TKR), a common treatment for end-stage osteoarthritis of the knee.

Methods: Data (n= 4,796) were obtained from the Osteoarthritis Initiative database, a longitudinal observational study of osteoarthritis. TKR patients (n=184) were matched to non-TKR patients, using propensity score matching on the predicted hazard of TKR, and exact matching on osteoarthritis severity and health-related quality of life (HrQoL). The economic evaluation using the matched control group was compared to the standard method of using the pre-surgery score as the control.

Results: Matched controls were identified for 56% of the primary TKRs. The matched control HrQoL trajectory showed evidence of RTM accounting for up to half of the estimated QALY gains from surgery using the pre-surgery HrQoL as the control. Incorporating RTM into the economic evaluation significantly reduced the estimated cost-effectiveness of TKR and increased the uncertainty. A generalized ICER bias correction factor was derived to account for RTM in cost-effectiveness analysis.

Conclusion: RTM should be considered in economic evaluations based on quasi-experimental pre-post studies.

The health care costs of childhood and adolescent obesity in Australia
Robert Hughes, Nicole Black; Sonja Kassenboehmer

Overweight and obesity in childhood increase the risk of childhood health problems including hypertension and type 2 diabetes and can lead to lowered self-esteem, depression, and other psychosocial problems. Although an increasing literature demonstrates that a significant relationship exists between childhood obesity and health care costs, there is limited evidence on whether this correlation is causal. Obesity may be endogenous to health care costs due to unobserved factors that may cause both obesity and higher health care utilisation. For example, depression (which may be undiagnosed) may be associated with both weight again and higher health care utilisation.  In this study we estimate the effect of childhood obesity on pharmaceutical and medical care costs incurred by the Australian Government using 6 waves of panel data from the Longitudinal Study of Australian Children, which is linked to Medicare Australia data. We employ a range of techniques including fixed-effects and instrumental variables (IV) estimators to address concerns about the endogeneity of obesity. In the IV models, we exploit the genetic variation in obesity as instruments. The results suggest a strong association between obesity and health care costs, which holds for some groups of children when we account for endogeneity concerns. We discuss the implications of our estimates for the economic rationale for government-funded obesity reduction policies.

High Spending on Maternity Care in India: What are the Factors Explaining It?

Background and Objectives
High maternity-related health care spending is often cited as an important barrier in utilizing quality health care during pregnancy and childbirth. This study has two objectives: (i) to measure the levels of expenditure on total maternity care in disaggregated components such as ANCs, PNCs, and Natal care expenditure; (ii) to quantify the extent of catastrophic maternity expenditure (CME) incurred by households and identify the factors responsible for it.

Methods and Findings
Data from the 71st round of the National Sample Survey (2014) was used to estimate maternity expenditure and its predictors. CME was measured as a share of consumption expenditure by different cut-offs. The two-part model was used to identify the factors associated with maternity spending and CME. The findings show that household spending on maternity care (US$ 149 in constant price) is much higher than previous estimates (US$ 50 in constant price). A significant proportion of households in India (51%) are incurring CME. Along with economic and educational status, type of health care and place of residence emerged as significant factors in explaining CME.

Findings from this study assume importance in the context of an emerging demand for higher maternity entitlements and government speding on public health care in India. To reduce CME, India needs to improve the availability and accessibility of better-quality public health services and increase maternity entitlements in line with maternity expenditure identified in this study.

1. Keep on keeping on: Predicting who will be able to work until they are 70 years old

Deborah Schofield; Rupendra Shrestha; Michelle Cunich; Dr Emily Callander

The Commonwealth Government announced in the 2015 budget that, in addition to increasing age eligibility for the Age Pension (official retirement-age) to 67 years by 2023, it plans to further increase eligibility to 70 years by 2035. Justification for these increases centred on increasing longevity, and costs of pension payments, health and aged care. However, the capacity of people to work not only depends on employment opportunities, but their health capacity. The aim of this study is to determine who is likely to be able to keep working until age 70.

We re-weighted the records of the population aged 45-69 years from the Australian Bureau of Statistics’ Surveys of Disability, Ageing and Carers 2009 and 2012 to reflect the population profile in 2015. We used a logistic regression model and Monte Carlo simulation to simulate the labour force status for each individual in 65-69 age group.

If the retirement-age was lifted to age 70, we estimated that, in 2015, the number of people aged 65-69 years who are likely to be not in the labour force would decrease to 627,700 from the estimated 818,970 under the current scenario. However, the percentage of those who would leave the labour force due to their ill-health among those not in the labour force would increase to 15.6% (97,700) from the current estimate of 1.5% (12,000). The five main chronic conditions likely to keep most people out of the labour force are: arthritis, back problems, diseases of the musculoskeletal system, diabetes, tumours/cancers.

This study provides evidence about the work capacity of people aged 65-69. This information can be used to develop policy consistent with the identifiable work capacity of individuals, rather than “assumed work capacity” based on increased longevity.The Commonwealth Government announced in the 2015 budget that, in addition to increasing age eligibility for the Age Pension (official retirement-age) to 67 years by 2023, it plans to further increase eligibility to 70 years by 2035. Justification for these increases centred on increasing longevity, and costs of pension payments, health and aged care. However, the capacity of people to work not only depends on employment opportunities, but their health capacity. The aim of this study is to determine who is likely to be able to keep working until age 70.

2. A literature review of productivity measures in intervention and cost of illness studies for osteoarthritis
Deborah Schofield; Sarah West; Michelle Cunich; Rupendra Shrestha

Aims: Review the literature to identify productivity measures in osteoarthritis (OA) studies; the scale of productivity costs captured; and determine productivity measures not captured.

Methods: A targeted literature search on Medline, Cochrane Library, EMBASE, Expanded Academic, Econlit (1/1/2010-11/6/2015) was undertaken for OA studies estimating productivity losses. Searches on productivity costs (e.g. labour, retire, financial, societal, time-off-work, carer, presenteeism, absenteeism, sick leave, employment, job, worker’s compensation, childcare, income, pension, productivity) and osteoarthritis in humans were undertaken by SW, MC. Original, peer-reviewed research-articles in English, published in the last 5 years, were deemed appropriate if they were interventions or cost of illness studies involving adults with OA with productivity as a key outcome.

Results: Search yielded 63 full-texts; 25 interventions, 37 cost of illness, 1 policy document. A range of methods had been used to estimate productivity losses, from a single question (such as time to return to work) to established questionnaires/instruments where several aspects of productivity were evaluated (such as the Work Productivity and Activity Impairment Questionnaire). However, many of the productivity measures from these questionnaires have only been assessed for face/content validity and feasibility in the last few years. Only 8 intervention studies and 4 cost of illness studies valued productivity losses. Available instruments had major limitations: no capacity to monetarise productivity impacts, excluded critical subpopulations (e.g. those out of the workforce due to OA), excluded obvious major costs (e.g. lost income) and other major costs (e.g. welfare, tax), and did not include a measure of productivity that could effectively be used in the translation to policy.

Conclusions: Productivity measures not captured were lost labour force participation and income for individuals, extra welfare payments and lost taxation revenue for government, and lost GDP.

A systematic review of cost-effectiveness studies of next-generation sequencing (NGS) in cancer care, and a proposal to assess the cost-effectiveness of NGS in cancer by developing a microsimulation model
Chien Yan Owen Tan; Rupendra Shrestha; Deborah Schofield

Next-generation sequencing (NGS) is a new tool in the management of cancer patients’ care. Genetic profiling by NGS is especially useful for oncologist in formulating targeted therapy strategy. However, the evidence of cost-effectiveness of the integration of NGS into cancer treatment programs is scarce. We undertook a systematic review of the published literature evaluating the cost-effectiveness of the use of NGS in planning targeted therapy for cancer patients. We systematically searched for articles that include cancer, NGS, and cost-effectiveness from both PubMed and EMBASE and included the articles that provided a measure of relative economic value through the application of NGS. The review only found three articles that undertook the cost-effectiveness analysis of the use of NGS in cancer care and all three articles reported that sequencing a panel of clinically relevant or actionable genes at diagnosis using NGS is cost-effective. . Our systematic review shows that there are very limited cost-effectiveness studies of the NGS application in cancer treatment planning suggesting a significant gap in knowledge about the cost-effectiveness of the NGS application in cancer care.,/p>

We are developing a microsimulation model to assess the cost-effectiveness of the use of NGS to formulate the targeted therapy for cancer patients. The model will use the survival data and cost of treatments from the published literatures together with the data linked by the Centre for Health Record Linkage (CHeReL) (including data from NSW cancer registries, NSW admitted patient registries, National death registry, NSW Perinatal Death registries and caused of death registries). The CHeReL dataset will also be linked to Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Schedule (MBS) to evaluate the medical cost of the disease. We will present the findings of our systematic review and discuss the data source and methodology of our microsimulation model in this presentation.Next-generation sequencing (NGS) is a new tool in the management of cancer patients’ care. Genetic profiling by NGS is especially useful for oncologist in formulating targeted therapy strategy. However, the evidence of cost-effectiveness of the integration of NGS into cancer treatment programs is scarce. We undertook a systematic review of the published literature evaluating the cost-effectiveness of the use of NGS in planning targeted therapy for cancer patients. We systematically searched for articles that include cancer, NGS, and cost-effectiveness from both PubMed and EMBASE and included the articles that provided a measure of relative economic value through the application of NGS. The review only found three articles that undertook the cost-effectiveness analysis of the use of NGS in cancer care and all three articles reported that sequencing a panel of clinically relevant or actionable genes at diagnosis using NGS is cost-effective. . Our systematic review shows that there are very limited cost-effectiveness studies of the NGS application in cancer treatment planning suggesting a significant gap in knowledge about the cost-effectiveness of the NGS application in cancer care.

The economic impacts of childhood syndromes of suspected genetic origin
Khurshid Alam; Deborah J Schofield; Susan M White; Clara Gaff

As part of a prospective study on the “Integration of genomic sequencing into clinical care” at the Royal Children’s Hospital in Melbourne, Australia, we undertook a detailed survey of the social and economic impacts of childhood syndromes of suspected monogenetic origin among the infants aged 0-2 years. In this paper, we report on the first wave of our survey on the quality of life impacts on the parents, their current labour force participation and income, impacts on their family planning behaviour, the parental marital relationship and social connectedness. Preliminary analyses show that 54% of the infants experienced hospitalisations in the last 12 months. The data also show that 68% parents were compelled to work part-time, and 18% are not in labour force at all. An assessment of the quality of life (AQoL-8D) of the parents shows their average overall utility score to be 0.71 (sd=0.21). Although their physical health score is close to the overall utility score (mean=0.76, SD 0.21), their mental health score is nearly half of the overall utility score (mean=0.38, sd=0.21). More than half of the parents (54%) have concerns of a further recurring genetic disorder among their future children, and 82% are taking steps to avoid pregnancy. However, two-thirds of the parents maintain healthy parental relationship.

Self-reported quality of life in residential care: An empirical comparison of the EQ-5D-5L and DEMQOL-U in an Australian residential aged care setting
Gang Chen: Billy Kaambwa; Richard Norman; Brendan Mulhern: Julie Ratcliffe

Aims: The main objective of this study was to empirically investigate the association between personality traits and self-reported health-related quality of life (HRQoL).

Methods: The 9th and 13th waves of the HILDA survey were used. Personality is classified according to the Big Five’ taxonomy: emotional stability, extraversion, openness to experience, agreeableness and conscientiousness. HRQoL was measured using the SF-36 which generates eight summary scores including physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. Each of the eight dimensions was treated as separate dependent variables in regression models. Both OLS and fixed-effects estimators were adopted for the analysis. Quantile regression techniques (for both cross-sectional and panel data) were also used to explore the association between personality traits across the distribution of self-reported HRQoL.

Results: In general, after controlling for an objective health measure (e.g. serious medical conditions informed by doctors/nurses) and an extensive set of socio-demographic characteristics, emotional stability and conscientiousness consistently demonstrated a significant positive association with all eight SF-36 dimensions in both waves. Overall, emotional stability was found to be the dominant trait in terms of the magnitude of association. Next, interaction terms between each of five personality traits and the objective health indicator were generated and included into the regression. The key result of the fixed-effects estimates indicated that conditional on the same objective health status, higher emotional stability was associated with relatively higher scores for the majority of the SF-36 dimensions (with the largest differences evident for the RE dimension).

Conclusions: Personality traits, especially emotional stability, are significantly associated with the way in which respondents self-report their HrQoL utilising the SF-36. Further investigation of the relationships between personality traits and assessment of HrQoL is warranted.

2. Investigating the association between personality traits and self-reported health-related quality of life
Billy Kaambwa, Gang Chen, Richard Norman. Brendan Mulhern, Julie Ratcliffe

Aims: A variety of economic, sociological and psychological factors have previously been shown to predispose individuals and populations to increased or reduced health care utilisation. However little evidence is currently available on the associations between personality traits and health care utilisation. The main aim of this study was to investigate the relationships between personality traits and health care utilisation in the Australian population.

Methods: Data for 22,266 individuals (53% female; mean age 44 years) who participated in waves 9 and 13 of the Household, Income and Labour Dynamics in Australia (HILDA) Survey were used. Using cross-sectional and panel logit regression models, we explored the relationship between the “Big Five” personality traits (Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness) and health care utilisation including health check-ups or tests, doctor (in both primary and secondary care) and other allied-health provider visits. The regression models were based on the Andersen behavioural model of health care utilization and controlled for predisposing characteristics (e.g. age), enabling factors (e.g. income) and need factors (e.g. general health).

Results: Cross-sectional regression models indicated stability of results over the two waves. Random-effects panel regression models showed that Extraversion and Agreeableness had a statistically significant positive relationship with all types of health care utilisation. Conscientiousness was negatively correlated to having health check-ups/tests or seeing a primary care doctor while Openness to Experience was shown to have a positive statistically significant relationship with seeing allied-health providers and a negative one with having health check-ups/tests.

Conclusions: Personality traits are associated with Australians’ use of many health care services. Person-centred interventions incorporating personality psychology may need to be considered in the future planning of Australian health care programs.

3. Is Personality Associated with the Health Care Utilisation of Australians?
Tiffany Easton, Rachel Milte, Maria Crotty, Julie Ratcliffe

Aims: To assess the acceptability and validity of self-reported generic (EQ-5D-5L) and condition-specific (DEMQOL-U) preference-based HRQoL measures in the residential aged care setting, where the population is characterised by high rates of cognitive impairment, dementia and disability.

Methods: This study was nested in a large cross-sectional, observational study to evaluate specialised dementia services currently provided in residential aged care in Australia. HRQoL was assessed by utilising the EQ-5D-5L and DEMQOL instruments. A battery of clinical outcome measures were applied to assess cognition, physical function, and neuropsychological symptoms. Spearman’s rank order correlations were used to examine the strength of association between HRQoL dimensions and clinical measures. Bland-Altman plots were generated to graphically assess agreement between the EQ-5D-5L and DEMQOL-U utilities.

Results: A total of 901 older people currently residing in 17 residential aged care facilities were approached, 541 consented (either directly or via a proxy) to participate. Of these, 143 participants completed both the EQ-5D-5L and DEMQOL instruments. Correlations between the EQ-5D-5L and DEMQOL-U were low to negligible across all dimensions. Physical functioning showed a moderately strong correlation with the EQ-5D-5L index. Higher levels of cognitive impairment were associated with lower EQ-5D-5L utilities. Neuropsychological symptoms were found to be weakly correlated with the DEMQOL-U index.

Conclusions: Our data suggest that the DEMQOL-U and EQ-5D-5L capture distinct aspects of HRQoL which complement typical clinical outcome measures applied in residential care. Whilst HRQoL forms an important outcome for quality assessment and economic evaluation, high levels of cognitive impairment may preclude self-completion for a majority of residents. It is therefore important that complementary strategies are developed to support self-reported HRQoL in this setting.

Proxy assessment of quality of life in a residential aged care setting for older people with cognitive impairment and dementia: An empirical comparison of the EQ-5D-5L and DEMQOL-Proxy-U
Shalika Bohingamu Mudiyanselage; Lisa Gold; Melissa Mulraney; Honey Heussler; Emma Sciberras; Nicole Rinehart; Nicole Hayes; Harriet Hiscock

Objective: Close to 70% of children with Attention Deficit-Hyperactivity Disorder (ADHD) have a sleep problem. The aim of this study is to examine the cost-effectiveness of the Sleeping Sound with ADHD translational randomised control trial in real-life clinical settings.


Intervention: Paediatrician practices in Victoria and Queensland, Australia recruited 320 Children aged 5-12 years old with ADHD for this cluster randomised control trial. Children allocated to the intervention had up to two face-to-face consultations and one phone consultation covering sleep hygiene and standardized behavioural strategies.


Methods: Cost-consequences analysis was conducted from health care and societal perspectives. Costs were estimated in 2016/17 Australian dollars. Training costs, paediatricians’ and psychologists’ consultation time costs and health service utilisation over 6 months were analysed in the economic evaluation.


Results: The intervention was associated with an average additional cost per study participant of $400 from a health service perspective. Most of the cost arose from staff training for the intervention. Data on outcomes and health service utilisation will be available in July 2017.


Sleep problems are common in children with ADHD. Australian community paediatricians can incorporate a behavioural sleep intervention into their practice, either themselves or through psychologist partners. This intervention has additional cost.

Model Development for and Preliminary Assessment of Real World Cost Effectiveness Model Development for and Preliminary Assessment of Real World Cost Effectiveness
Befikadu Legesse Wubishet; Win Thu; Sophie Langenskild; Jonas Lundkvist 

Background: Novel oral anticoagulants (NOACs) have, in clinical trials, shown to be more efficacious and safer for preventing thromboembolic complications of atrial fibrillation (AF) compared to warfarin. They also seem to be cost-effective, even though their acquisition costs are much higher. As regulatory- and health technology-bodies increasingly require evidence of cost-effectiveness of drugs in clinical practice, there is a need to determine this value for money in real world.


Aim: To develop a model for and preliminary assessment of real world cost-effectiveness of NOACs among AF patients in Sweden.


Method: A systematic review was conducted in order to summarize previous evaluations. A Markov model consisting of thromboembolic and bleeding states was developed in Excel. The population in the model was AF patients with CHA2DS2-VASc score≥2, and starting age 65 years. The model was populated for Swedish context with specific input data.


Results: A Markov model with health states non-valvular AF, ischemic stroke, pulmonary embolism, deep vein thrombosis, myocardial infarction, intracranial hemorrhage, gastrointestinal bleeding, minor bleeding, post ischemic stroke, post myocardial infarction, post intracranial hemorrhage and death was developed. Three-month cycle length, life-time time horizon and societal perspective were employed. The base case incremental cost effectiveness ratio was SEK 319,724/QALY which might make the NOACs cost-effective in reference to willingness to pay of SEK 500,000/QALY. NOACs dominated warfarin when warfarin time in therapeutic range was 66%.


Conclusion: This study developed a Markov model which can be applied in Swedish clinical practice. Based on the developed model and data with which it has been populated, NOACs are cost effective. To make the model fully representative of clinical practice, age specific transition probabilities and relative risks of AF complications and mortalities need to be replaced with real world data.

Cost effectiveness of hospital‐based versus home‐based immunoglobulin replacement therapy for patients with primary immunodeficiency
Tanja Windegger; Karen Morwood; Helen Weston; Lin Fung; Kim Nguyen

Background: Immunoglobulin replacement therapy (IRT) accounted for 48% of Australia’s total blood budget in 2014-15. Hospital-based intravenous immunoglobulin (IVIg) is the predominant form of IRT in Australia, with only 1.52% being home-based subcutaneous immunoglobulin (SCIg). In contrast, in the USA and Europe approximately 50% of patients are using SCIg. Objective: This study evaluates the cost-effectiveness of a hospital-based (IVIg) and a home-based (SCIg) treatment option for patients with primary immunodeficiency disorder (PID)


Method: We develop a Markov cohort model to capture a typical patient’s treatment pathway and calculated the incremental cost, incremental outcome and the incremental cost effectiveness ratio. Sensitivity analyses are conducted on the influential cost and outcome factors to understand the level of uncertainty around the cost-effectiveness results. Data are collected from various sources, including surveys (health-related quality of life using the AQoL-6D), administrative data (treatment costs) and literature (transitions probabilities).


Results:Preliminary results indicate that the home-based (SCIg) treatment is a cost-effective option for patients with primary immunodeficiency disorder (PID). Although the treatment interval is shorter (weekly), the medication cost is comparable to the hospital-based (IVIg) and the overall cost reduction comes from reduced hospital outpatient cost. Additionally, patients who access the home-based treatment have lower risk of nosocomial infections, which leads to fewer inpatients admissions and delays subsequent development of bronchiectasis.


Conclusion Home-based SCIg is a cost effective alternative treatment mode that is preferred by patients with difficult venous access and who prefer the flexibility of home treatment. Hence increased SCIg programs availability would be benefit both patients and the health service provider.

Capturing Equity Considerations in Cost‐Effectiveness Analysis: A Systematic Review of Rotavirus Vaccine in Low‐ and Middle‐Income Countries
Marie-Anne Boujaoude; Andrew Mirelman; Kim Dalziel; Natalie Carvalho

Background: Cost-effectiveness analysis (CEA) seldom incorporates information about trade-offs between total health gains and equity impacts of interventions. This study investigates to what extent equity considerations are taken into account in CEA in low- and middle-income countries (LMICs), using rotavirus vaccination as a case study.


Methods: Using the Guidance on Priority Setting in Health Care (GPS-Health) checklist, specific indicators were mapped to each of 10 equity criteria. Thereafter, CEAs of rotavirus vaccine in LMICs identified by a systematic review were assessed to explore the extent to which those equity criteria were considered in the research objectives and analysis, and whether they were reflected in the results.


Results: Fifty-nine studies were identified. The 10 equity criteria in the GPS-Health checklist were mapped to 16 unique indicators, of which 5 were not applicable to rotavirus vaccine. Most studies incorporated 2 indicators within the analysis: age considerations (81%) and severity of the disease (75%). Fewer studies considered a societal perspective (58%), caregiver’s productivity losses (42%), relative coverage (31%) and geographic area (27%); and an even smaller proportion accounted for indirect benefits (herd immunity) (12%), household income level (8%), presence of comorbidities (6%), financial risk protection (5%) and gender (5%). Some articles only incorporated the indicators in their model inputs while others presented results differentiated according to the indicators. We detected trends over time in how equity criteria were considered. For example, age weighting of DALYs has declined over time, while accounting for financial risk protection through extended CEA was noted in three recent studies.


Conclusion: Integrating equity criteria in CEA is feasible, and can help policy-makers better understand the distribution of the impact of interventions within society. This study highlights how equity considerations are incorporated within CEA in practice and identifies possible areas of improvement.

The impact of increasing vegetable consumption on government health expenditure in Australia
David Creelman; Lynne Pezzullo; Jared Streatfeild

Background: There is a well-established link between increased intake of vegetables and improved health outcomes, which includes reductions in the incidence and mortality of specific cancers and cardiovascular disease (CVD). Levels of vegetable consumption by Australian adults are lower than recommended by national guidelines. Australian adult females eat more vegetables than Australian adult males.


Objectives: To quantify the potential reduction in government health expenditure due to increased vegetable intake.


Materials and methods: An attributable fraction approach was taken to define the burden of disease and subsequent health expenditure associated with specific cancers and CVD that were attributable to low vegetable consumption. Meta-analysis results were used to fit second-order polynomial relative risk curves for specific cancers and CVD at different consumption levels. Government health expenditure data were obtained from the Australian Institute of Health and Welfare. The impact on government health expenditure was proxied using marginal changes in incident risk for the specific cancer types and CVD. Two scenarios were run based on hypothetical counterfactuals relative to the current state: (1) if vegetable consumption was 10% higher and (2) if male consumption was equal to female consumption.


Results: Government health expenditure was $99.9 million lower in Scenario 1, and $58.0 million lower in Scenario 2, in Australia in 2015-16. The largest reduction was in the 65-74 years age group.


Conclusions: The results of this analysis present a compelling argument to address the social, environmental and economic barriers to increasing vegetable consumption. Further research is needed to develop policies which drive an increase in vegetable consumption.


Funding and disclosures: This project was funded by Horticulture Innovation Australia using the National Vegetable Levy and Australian Government funding. Deloitte Access Economics received consulting fees from Horticulture Innovation Australia as part of the study conduct and development.

Edgar Sydenstricker: The first health economist?
Philip Clarke and Guido Erreygers

Abstract: The economist Edgar Sydenstricker, who spent most of his working life at the United States Public Health Service and at the Milbank Memorial Fund, examined a wide range of health economics issues. He was appointed as the first statistician of the United States Public Health Service in 1915 and immediately contributed to debates around the cause of the disease pellagra. Sydenstricker used a range of statistics including time series on food prices and household incomes to correctly argue that it was due to a dietary deficiency. This research was followed by many studies quantifying income-related health inequalities including the mortality associated with the influenza pandemic of 1919 and the health of workers in the garment industry. Sydenstricker’s contribution was not just confined to analysis: he was heavily involved in the use of surveys to collect information and he was instrumental in the development of the first US National Health Survey. Other contributions include extending health insurance in the United States and methods of evaluating public health programs that involve assessment of costs and outcomes. His activities were cut short by his death in 1936. While recognised for his contributions to epidemiology, his contribution to health economics has largely been forgotten.

Health care and the future of economic growth: a preliminary discussion of alternative perspectives
Martin Hensher

The strong and positive relationship between GDP and health expenditure is one of the best-explored topics in health economics. However, since the Global Financial Crisis, a variety of theories attempting to explain the slow recovery of the global economy have suggested that in the developed countries, if not globally future economic growth may be slower than in the past. Others have increasingly questioned whether GDP growth is desirable or sustainable in the long term. Yet the consequences of lower future growth rates for health care systems appear not to been explored in the economics or health economics literatures.


This paper reviews recent data on trends in global GDP growth and health expenditure. It examines a range of theories and scenarios concerning future GDP growth prospects, under the broad headings of structural low growth, self-inflicted low growth, fragile and financialised growth, unequal growth, undesirable and unsustainable growth, and endless cycles or infinite growth? It then considers the potential implications for health care systems and health financing policy of these different scenarios. It concludes that sustaining health care systems under low growth, “agrowth” or “degrowth” futures may require significant departures from the policy orthodoxy of recent decades. In particular, there appear to be several grounds for considering public financing to be superior private health financing, for reducing rent-seeking opportunities in the health insurance and pharmaceutical sectors, and for intensifying the focus on reducing low-value care. Applying insights from heterodox economic thinking to health care systems may require not only better use of appropriately calibrated cost-effectiveness analysis, but also a greater role for normative and ethical values in understanding the consequences of constrained growth scenarios.

The Welfare Effects of Hospital Subsidies to Hospital‐Based Physicians
Eric Sun; David Mauler

In the United States, private insurers pay more than public insurers. As a result, physicians prefer to practice in areas with favorable payer mixes (e.g., higher percentage of privately insured patients), and physicians in areas with less favorable payer mixes tend to limit the number of publicly insured patients they see. However, hospital-based physicians, who care for hospitalized patients or patients seeking care at a hospital (e.g. anesthesiologists, emergency room physicians), typically cannot refuse to see patients. As a result, hospitals with less favorable payer mixes can have difficulty recruiting these physicians. Indeed, many hospitals must make additional side payments in order to recruit hospital-based physicians. These side payments are the results of negotiations between physicians and hospitals and typically are not publicly reported.


In this paper, we analyze these side payments using a novel dataset that details the size of these payments for hospitals in California. First, we develop a model to analyze the welfare effects of these side payments. In this model, hospitals (and physicians) face two types of patients: publicly insured and privately insured patients. The price for the former is set by the public insurer at a below-market price, while the price for the latter is set in the market. Our model finds that, when hospitals have more market power than physicians (as is empirically likely to be the case), the side payments are welfare reducing, because hospitals pass along the costs of these side payments—plus a markup—to privately insured patients. By contrast, it would be more efficient for the public insurer to simply pay a market rate for medical services. Second, using our dataset, we provide a descriptive analysis of these side payments, and use our model to calibrate the potential welfare losses associated with these payments.

Effects of Physician Risk Preferences on Their Decisions to Adopt New Prescription Drugs
Yuting Zhang; Susan Mendez; Anthony Scott

Risk preferences play a fundamental role in decision making under uncertainty. In this paper we investigate how risk preferences of Australian general practitioners (GPs) affect their decisions to adopt new prescription drugs – novel oral anticoagulants (NOACs) “ a category of drugs with high perceived risk” for the prevention of stroke or systemic embolism. We use prescription records from the Pharmaceutical Benefit Scheme (PBS) linked to detailed individual doctor-level panel data on a sample of around 900 GPs from the Medicine in Australia: Balancing Employment and Life (MABEL) survey. Preliminary findings show associations between risk attitudes and speed of adoption.

Using multilevel analysis to prioritize pay‐for‐performance (P4P) incentive design features: should we aim at patient or facility for better quality improvement?
Tsung-Tai Chen; Ya-seng (Arthur) Hsueh;Ling-Na Shih; Sien-Sing Yang

Objectives: This study examines the effect of National Health Insurance Administration (NHIA)’s new pay-for-performance (P4P) program in Taiwan. We aim to investigate whether the extra financial incentive currently targeted at the patient aspect is appropriate for improving related hepatitis B or C examination completion rates.


Methods: Using claim data in the NHIA’s database from 2009 to 2012, we treat hepatitis B and C patients (experimental group-P4P patients and control group-Non-P4P patients) in 2010 as a cohort, tracing them to year 2012 and tracing back to 2009. A ratio of 1:1 in propensity score matching based on observable factors of patients who belong to P4P group and those who belong to Non-P4P group. We employ generalized linear mixed model (GLMM) for multilevel analysis (includes both patient-level factors and facility-level factors) on two major examination completion rates.


Results: We found patient-level factor-participation status and facility-level factor-facility size are significant and the most powerful explanation factors of examination completion rated. However, for the completion rates of blood tests, few of the variations reside at the facility side (intra-class correlation coefficient [ICC] around 20%), and for the completion rates of abdominal ultrasound examination, a large facility-level variation exists at the facility side (ICC around 50%)


Conclusions: Using multilevel analysis helps to identify which level should be considered with priority for improving specific outcome measures of P4P. The P4P incentive currently targeted solely at the patient aspect is not adequate because it can result in a better rate of blood tests but not the rate of abdominal ultrasound examination. The findings of this study provide crucial information on how this problem can be improved.

The effects of blood pricing and clinical guidelines on the use of blood in cardiac surgery
Adam Irving; Anthony Harris; Dennis Petrie; Zoe McQuilten

The aim of the study is to determine whether explicit charging for blood is an effective incentive to improve the efficiency with which it is used. Blood has traditionally been provided to Australian hospitals by the National Blood Authority (NBA) free of charge. Hospitals are not motivated to limit consumption in the absence of a budget and accompanying price. Assessed against current clinical guidelines, there is evidence of inappropriate, excessive use of blood in Australian hospitals.


Since 2005 a number of Australian states have devolved their budgets for blood down to local hospital networks and posted explicit unit prices. The introduction of a cost for blood in the context of a fixed price per unit creates an incentive for hospitals to use blood efficiently.


In 2012 the NBA published national patient blood management (PBM) guidelines focussed on perioperative care. The guidelines aim to shift transfusion practices away from routine blood use, towards patient-centred, evidence-based prescriptions only when clinically necessary.


This study uses data from the Australia & New Zealand Society of Cardiothoracic Surgeons (ANZSCTS) database to determine whether the national perioperative PBM guidelines were more effective at reducing inappropriate blood use in cardiac surgery in states with or without devolved budgets for blood. The analysis is performed using a difference-in-differences framework controlling for the large set of patient, surgery, and surgeon characteristics available in the ANZSCTS database.


We hypothesise that the PBM guidelines will result in a larger reduction in blood prescriptions in an environment of a devolved budget and an explicit price. The causal effect of blood pricing on outcomes is estimated using a state and month fixed effects regression model. The analyses test for time-varying treatment effects on outcomes of blood and blood product use, length of stay, mortality, infection, and renal failure.

Evidence of the cost effectiveness of WGS in familial intellectual disability: capturing the social and economic ripple effects of intellectual disability on families
Deborah Schofield; Michael Field; Jackie Boyle; Louise Christie; Lucinda Murray; Sarah West; Rupendra Shrestha; Nadine Kasparian; Tony Roscioli.

We are undertaking a study of the economic and social impacts of WGS of familial intellectual disability with the Genetics of Learning Disability (GoLD) service. However, there is little data on the many impacts families face to undertake such a study: financial pressure, relationship strain, poorer caregiver health, and uncertainty about family planning. With advances in genomic testing, families can benefit from an increased diagnostic rate, targeted therapy where available and advice on recurrence, restoring reproductive confidence.


Currently there is no comprehensive economic model of the benefits of genomics for intellectual disability. Typically health economic models rely on aggregate information, using average patient, costs and quality of life associated with disease states, do not capture the interrelationship between the heath of one individual and others in a family, and the costs captured are generally limited to the health system.


Our multidisciplinary team designed a series of questionnaires to capture the large and diverse health, social and economic impacts of intellectual disability taking into account impacts within and beyond the health system, and the multi-person and intergenerational impacts. These questionnaires capture detailed information on the proband and primary care giver, including costs of testing and treatment, quality of life (HUI and AQoL), employment, welfare, family planning, education, relationship strain and social connectedness. The data from these questionnaires will be used to develop the world’s first microsimulation model capturing the diverse and interrelated policy impacts for State and Federal Government including the health and social costs at the individual and population level.

Economic impacts of targeted lifestyle weight loss intervention vs standard diet on FTO genotype in addressing obesity
Sharyn Lymer; Deborah Schofield; Stephen Colagiuri

Background: Australia has one of the highest levels of obesity amongst OECD countries. Personalised nutrition based on genotype profiles offers a potential novel method for addressing obesity. This study considered the cost-effectiveness of a weight loss program using high protein diet compared to low protein diet amongst individuals with FTO rs1558902 A genotype in the Australian population.


Methods: NCDMod, an Australian microsimulation model was used for evaluation. Counterfactual analysis was undertaken based on a weight loss intervention of high protein diet versus a low protein diet offered over two years targeted at persons with FTO rs1558902 A genotype who were overweight or obese aged 30-70. Scenario 1 offered the high protein diet intervention to eligible individuals and Scenario 2 offered a low protein diet intervention to eligible persons. On average the high protein diet resulted in 9% weight loss and the low protein diet 4%. The scenario parameters were based on the POUNDS LOST trial reported findings. The cost of the intervention was estimated using Medicare fees. Key outcomes were reduction in number of persons with obesity by 2025 and costs saving to the health system between 2015 and 2025 after 2 years implementation.


Results: Approximately 100,000 adults were simulated to complete the intervention in each scenario from 126,000 who commenced intervention. The scenario 1 simulated almost 13 500 less adults with obesity than scenario 2 in 2025. The cost of intervention per case of obesity avoided was $8044. The additional health system saving of scenario 1 over scenario 2 was $Au70.5 million.


Conclusions: A high protein dietary intervention for individuals with FTO rs1558902 genotype A has the potential to offer substantial savings to the health system through reduction in persons with obesity compared to offering a low protein diet to individuals with this genotype.

Estimating hospitalisation cost of childhood cancer via a microsimulation model: a proposal to assess the impact of high throughput sequencing in childhood cancer care
Owen Tan; Rupendra Shrestha; Deborah Schofield

Background: Cancer is a genetic disease driven by germline or somatic mutations. High-throughput sequencing (HTS) is envisaged to have a significant impact on the management of childhood cancer. Uptake of HTS has increased dramatically due to significant cost reduction and broader community acceptance. However, there is no economic evaluation of HTS in the treatment of childhood cancer. We propose to build a microsimulation model to estimate the healthcare cost of childhood cancer and to simulate and compare the impact on hospital usage of high-risk cancer patients had they receive HTS directed precision medicine. The availability of individual level data will allow us to better predict the possible economic impacts of precision medicine.


Methods: We will build a microsimulation model based on de-identified hospital admission data of childhood cancer patients from the CHeReL linked datasets. Records for patients under 18 will be obtained from the NSW Central Cancer Registry and linked to NSW Registry of Births, Deaths, and Marriages, the NSW Admitted Patient Data Collection, and NSW Emergency Department Data Collection. The linked dataset will have hospital admission/emergency department attendance data for approximately 10,000 cancer patients of aged under 18, which will serve as a base population of our microsimulation model. We will use this microsimulation model to estimate hospital services usage and the costs of hospitalisation.


We will be presenting the model framework, and the propose method of simulating impact of HTS on childhood cancer hospitalisation usage using our model.


Conclusion: Presently, clinical trials that aim to assess the effectiveness of HTS in the management of childhood cancer are underway in Australia and overseas. We will use the published results of these clinical trials to simulate the clinical and economic impact of using HTS in childhood cancer care in our base population.

The development of a microsimulation model of the cost‐effectiveness of population based genetic screening for breast and ovarian cancer
Michelle Cunich; Deborah Schofield; Alison Trainer; Lisa Devereux; Paul James; Lara Petelin; Ian Campbell

Background: Preliminary work on 3,889 cancer-free Australian women demonstrated the high acceptability and feasibility of genetic screening for breast and ovarian cancer through Familial Cancer Clinic (FCC) referral. However, the cost-effectiveness of proactive population-based genetic screening compared to Familial Cancer Clinic (FCC) referral (standard practice) is unknown.


Aim: To assess the cost-effectiveness of population-based screening of unaffected women for pathogenic mutations in high penetrance breast and ovarian cancer predisposition genes (BRCA1, BRCA2, PALB2 and ATM) followed by FCC referral compared to standard practice using a microsimulation model, GenBreastCAMOD.


Methods: The development of GenBreastCAMOD will be outlined – the first microsimulation model for assessing the lifetime health outcomes and costs of population-based genetic screening for breast and ovarian cancer in a Western population. The base population will consist of 10,000 cancer-free women (aged 50-plus) in the Lifepool prospective cohort attending BreastScreen Australia who take up proactive screening for breast and ovarian cancer predisposition genes and whose family are also invited for screening. A counterfactual will be assembled as the group who do not have proactive screening. Relevant data sources for health outcomes and costs will be discussed. The model will be used to analyse how the increased health outcomes and costs at a family-level from wider population screening compare to the counterfactual who have not had screening. It will also be used to assess the role of family history in women with positive gene mutations compared to those under FCC referral.


Conclusions: Proactive population-based genetic screening of breast and ovarian cancer is likely to generate gains in quality of life and lower costs for women and families. Results from GenBreastCAMOD will also be used to highlight the potential economic impacts of population-based genetic screening for other cancers and diseases.

Employment, occupational mobility and job skills of cancer survivors
Eskil Heinesen; Susumu Imai; Shiko Maruyama

The share surviving cancer has increased considerably due to improved medical technologies and the majority of cancer survivors who were employed before cancer return to work. We estimate effects of surviving cancer on labour market outcomes four years after the diagnosis using individuals without cancer as a control group. We use Danish administrative data combined with detailed skill requirement data constructed from the US O*NET database to investigate whether cancer effects vary by skill requirements in the baseline occupation, whether such heterogeneity can explain educational gradients found in earlier studies, and whether cancer is associated with changes in job characteristics for cancer survivors who remain employed. We find that cancer reduces the probability of employment by about 7 percentage points; the negative effect of cancer is larger if the baseline occupation requires a high level of manual skills or low level of cognitive skills; educational gradients are significant, but they diminish substantially if we allow the cancer effect to depend on both education and pre-cancer job skill requirements; for those who remain employed, cancer is not associated with mobility in terms of occupation, plant, or industry, or with changes in job skills, indicating potential for policies that reduces labour market frictions for cancer survivors to diminish welfare dependence and alleviate the negative effect of cancer on labour-market participation. Further analyses confirm the robustness of our results.

The impact of an Autism Diagnosis on Maternal Labour Supply
Angela Jackson; Dennis Petrie; Michael Shields; Anthony Harris

Australia is in the process of rolling out the National Disability Insurance Scheme (NDIS) which aims to reduce the long term costs of disability and improve the economic participation of both people with a disability and their carers. People with autism currently make up around 28 per cent of all participants in the NDIS.


Autism is a disorder characterized by impairments in social interaction and communication, and a preference for repetitive behaviors and has its onset in childhood. Improving understanding of the impact of autism on the labour force participation of parents, and the possible impact of greater supports provided under the NDIS will provide a solid evidence base to evaluate the impact of the NDIS in improving the economic participation of mothers.


Utilising the first six wave of the Longitudinal Survey of Australian Children (LSAC) we investigate the impact of having a child with autism on the labour force participation of mothers. Mothers may either increase labour force participation to pay for additional services for their children or decrease labour force participation to provide more care their autistic.


Using individual fixed effects we find support for previous studies on the impact of autism on maternal labour supply, with the impact of a greater caring role dominating. We extend the analysis by taking advantage of the introduction of significant additional supports during wave 3 of LSAC. Using difference in difference estimation we investigate whether additional assistance for autistic children impacted maternal labour supply.

Spillover Effects of Retirement on Partners: The Role of Long‐term Health Preconditions
Dominic Byrne; Do Won Kwak; Kam Ki Tang; Myra Yazbeck

There is a large literature on the impact of retirement on own health. But very recently, there is a growing interest in understanding the health impact of retirement beyond oneself. This paper contributes to this growing literature by investigating the spillover effect of a person’s retirement on the spouse’s health in the Australian context.


Given the inherent endogeneity associated with entry into retirement, we employ a Fuzzy Regression Discontinuity Design (FRDD) to exploit the exogenous variation in retirement status induced by age pension eligibility and superannuation accessibility. Using data from the Household Income and Labour Dynamics (HILDA) survey, we consider a range of physical and mental health outcomes measured based on the SF-36, as well as the quality-adjusted life-year (QALY).


Superannuation accessibility is found to have indiscernible impacts on people’s retirement decision, and so is the age pension eligibility on females’. Therefore, the main focus of our paper is on the health spillover effects of males’ retirement. The results show that the retirement of the husband has a positive impact on the physical and mental health outcomes and the QALY of the wife, but these benefits are confined to partners who are themselves retired and have long-term health conditions.


This research can have implications for health care options. Formal long-term health care is expensive, but informal care provided by family members can be a (partial) substitute. In Australia, the current carer allowance is less than 15% that of the retirement pension. For people who are capable of providing informal care to their family members but need to work for financial reasons, it may be cost-effective for the government to provide a much higher carer pension to encourage them to become a full-time carer.

Differences in paid income between women with children and without children and the impact of childbearing on income from paid employment: Evidence from Australia HILDA data
Julie Abimanyi-Ochom; Melissa Graham; Ann Taket and Jennifer J Watts

Introduction: There is a perception that women without children (WWOC) contribute to society less than women with children due to their lack of childbearing. This is despite evidence suggesting that WWOC contribute through employment, tax payments, volunteerism and other civic activities. However any differences in income or earnings has generally been presented as the “motherhood penalty”, rather than the positive contribution of WWOC.


Aim: To explore the nature and magnitude of the “motherhood penalty” amongst Australian WWOC; and to examine the association between the number of children and income from paid employment for women with children.


Method: Data from 14 waves (2001-2014) of the Household, Income and Labour Dynamics in Australia (HILDA) Study were used to estimate pooled OLS, Fixed Effects and Random Effects models. Fixed effects model controls for time-invariant confounding (within-person differences), while the random effects model controls for between person differences in income from paid employment associated with motherhood. The dependent variable is cumulative paid income over the 14 years and main explanatory variable is motherhood.


Results: Results reveal WWOC earn less income from paid employment. However, this deficit is reversed when age and being childless are included as an interaction term. Having one child does not affect a mother’s income from paid employment while, having two children or more significantly reduces their income with increased reduction for 3 children or more.


Conclusion: The findings suggest that a “motherhood penalty” favours women with children, contrary to other studies. Considering age in addition to being childless reverses the ‘penalty’ to favour childless women, similar to earlier studies. Among women with children, having more than one child reduces income, and this is comparable to Australian and international evidence

Modelling life course BMI trajectories among different socioeconomic groups in Australia
Alison Hayes; Thomas Lung; Andrew Tan

Background: Obesity disproportionately affects the most socioeconomically disadvantaged groups, yet modelled economic evaluations rarely take account of socioeconomic position (SEP). Our objective was to modify a validated micro-simulation model, to simulate BMI trajectories and obesity trends of Australian adults according to SEP. This model will provide the framework for modelled economic evaluation of obesity prevention and treatment in adults.


Methods: The study participants were 2901 male respondents of the 1995 National Nutrition Survey and 4001 from the 2011/12 National Health Survey, with full data on measured height, weight and school completion. We used a synthetic cohort technique which matches members of cross-sectional surveys by birth year, and regression modelling to derive equations for annual change in BMI based on age, sex, current BMI and SEP (based on education). Using an input population representing >3.5m adult men, in 1995 including BMI distribution, we used the micro-simulation model to project BMI trajectories and obesity prevalence by SEP over three decades to 2025 and validated against population level data.


Results: We found a significant effect of SEP on annual BMI gain for men under 50 years (p=0.038) and over 50 years (p< 0.001), with much greater inequality in weight gain by SEP for older men. Simulations showed widening inequality in BMI trajectories and projected obesity over the adult life course. For example, in 1995 the prevalence of obesity among 30-39 year old men was 15% and 20% (low and high SEP groups); but by 2025 when aged 60-69, it was projected to be 37% and 55%.



Conclusions: The inequalities in obesity already present in 1995 were projected to widen by 2025, with lower socioeconomic groups at higher risk of extreme obesity and its consequences. Prevention efforts should focus on these vulnerable population groups.

Model framework to determine cost‐effectiveness of childhood obesity preventions
Andrew Tan; Alison Hayes

Background: Timely prevention of childhood obesity is important because many obesity-related behaviours are established in, and track, from early childhood. We aim to develop a model framework for economic evaluation of childhood obesity prevention initiatives, that includes modelled body mass index (BMI) trajectories, obesity prevalence, and long-term cost and quality of life outcomes. Our first step is to develop a child-specific BMI trajectory model that considers the impact of socioeconomic position (SEP).


Methods: Subjects were 11,221 boys (aged 7-14) from the nationally representative Longitudinal Study of Australian Children (LSAC). Linear regression analysis was used to derive equations to predict annual BMI change by age, current BMI and SEP. SEP was measured as a composite variable that takes into account parental income, education and occupation. We used a micro-simulation methodology to model changing BMI of children over time. Our model was validated retrospectively against LSAC data.


Results: SEP had a significant effect on annual BMI change of boys (p=0.002), with higher gain observed in low SEP group compared to high SEP group. Obesity prevalence was higher in low SEP group across all ages. For example, among 7-year olds, obesity prevalence was 9% and 5% in low and high SEP groups, respectively. Our BMI trajectory simulations showed a widening inequality over time between high and low SEP. By age 14, our model predicted mean BMI of boys in lower and higher SEP at 21.9 (95% CI 21.6 – 22.1) and 20.4 (95% CI 20.2 – 20.6) respectively.


Conclusion: Our model predicts differences in BMI trajectories of children by SEP, which will result in widening of the obesity gap among children when they reach adolescence. To address this inequality, childhood obesity prevention interventions should target children from disadvantaged socioeconomic background.

Modelling quality‐adjusted life expectancy for Australian adult males by body‐mass index categories and socio-economic position
Thomas Lung; Andrew Tan; Alison Hayes

Background: Adult obesity is associated with an increased risk of adverse health outcomes and reduced life expectancy (LE). However, differences in quality-adjusted life expectancy (QALE) when stratified by socio-economic position (SEP) and weight status has not been explored in Australia.


Aim: To predict and compare remaining QALE of young Australian males aged 20-29 and 30-39 by SEP and by body-mass index (BMI) category.


Methods: An individual level discrete time simulation model was developed integrating annual change in BMI based on age, sex, and SEP, combined with published all-cause mortality and health-related quality of life data.


Simulations were run over a lifetime using an input population representing over 2m males aged 20-39 years from the 1995 Australian National Nutrition Survey. Utility weights by BMI status were taken from published literature.


Results: For 20-29 year males with obesity, we estimated remaining QALE to be 32.3 (95% CI 31.5 – 33.1) and 33.0 (95% CI 32.2 – 33.9) years, low and high SEP respectively. Similar results were found for the 30-39 year cohort with obesity, with an estimated 27.9 (95% CI 27.2 – 28.5) and 29.1 (95% CI 28.5 – 29.6) remaining QALEs (low and high SEP). In both SEP groups, the difference in remaining QALE between the healthy and obese group was approximately 13 and 10 QALYs in the 20-29 and 30-39 age groups, respectively.

Markov modelling incorporating socioeconomic position: application to an analysis of a sugar sweetened beverage tax
Anita Lal; Ana-Maria Mantilla-Herrera; Lennert Veerman; Vicki Brown; Marj Moodie; Rob Carter; Anna Peeters

Background and Aim: This presentation aims to assess the impact of obesity interventions in different socioeconomic groups. A Markov cohort model, developed for modelling the health effects of changes in body mass index (BMI) in the Australian population, was modified to incorporate socioeconomic position (SEP). The methods of inclusion of SEP into the model and its application to analyse the equity and cost effectiveness of a sugar sweetened beverage (SSB) tax will be discussed.


Methods: The model uses a multi-state, multiple cohort life table approach to translate changes in mean BMI following an intervention into corresponding health adjusted life years (HALYs) gained. Using the Socio-Economic Indexes for Areas (SEIFA) Index, quintile-specific sub-models were created by substituting key input parameters with SEIFA-quintile-specific data. These variables included disease incidence, mortality rates, BMI distributions and population numbers. To apply the effects of a SSB tax, SEIFA specific consumption of SSBs and price elasticities by income group were used. Concentration indexes to measure the health inequality impact based on the HALYs gained were calculated for various tax scenarios including 20%, 30%, 50% pass through of a 20% tax, 50c per litre, and the inclusion of flavoured milk.


Results: Quintile specific models allowed the comparison across SEP groups of health benefits and financial impacts of the tax, such as HALYs gained, health care cost savings and out-of-pocket costs. The tax would be cost saving across all quintiles, with 49.5% of the total health gains accruing to the two lowest quintiles. Concentration indexes were negative indicating that health equity would be improved under all tax scenarios.


Conclusions: The incorporation of SEP into cost-effectiveness analysis provides policy makers with additional information about the health equity impacts of public health policies.

Adjustment Costs and Incentives to Work: Evidence from a Disability Insurance Progam
Arezou Zaresani

How important are adjustment costs for individuals when they face incentives to work induced by a policy change? I provide the first estimate of heterogeneous adjustment costs by exploiting a unique policy change that induces large incentives to work. The policy change dramatically decreased marginal tax rates on earnings in a non-linear tax schedule on earnings in a disability insurance program in Canada. Individuals continue to bunch at the location of a kink even when the kink no longer exists, suggesting that they face adjustment costs when changing their labor supply. I use the amount of bunching at the kinks before and after the policy change to estimate the size of adjustment costs that vary by individuals’ ability to work. The estimated adjustment costs are higher for individuals with lower ability; varying from zero to 8 percent of their potential earnings. The estimated elasticity of earnings with respect to tax rates – accounting for heterogeneous adjustment costs – is 0.2 which is double the size of the one estimated with no adjustment costs. The policy change also decreased the marginal tax rates far away from the kinks. I then evaluate the overall effects of the policy change on the labor supply using a Difference-in-Differences design. I find that some individuals work more and some others start working in response to the large induced incentives to work. Accounting for the adjustment costs then might explain the disparate findings on the effects of increase in incentives to work on labor supply in disability insurance programs. My findings therefore have important implications for designing policies and targeting heterogeneous groups to increase labor supply in disability insurance programs.

Unintended Consequences of Supply‐Side Cost Control? Evidence from China's New Cooperative Medical Scheme
Marc K. Chan; Guohua Zeng

We use hospital administrative records to analyze the fee limit policy of a universal health insurance program in rural China. Synchronous with periodic assessment cycles of hospital departments, we find that the average inpatient fee in the last week of the month is higher by 6 to 9 percent relative to the first week of the month. This cyclical pricing anomaly is consistent with a behavioral model, in which hospitals screen out high-cost patients dynamically in order to comply with the fee limit policy. Our results suggest that the fee limit distorts hospitals’ pricing behavior in unexpected ways, which have negative implications for patient welfare.

Implementation of a surveillance protocol for individuals at high risk of melanoma in Australia from a research study to practice in the community
Caroline Watts, Rachael Morton,, Sarah Norris , Sally Wortley,, Scott Menzies,, Pascale Guiterra, Graham Mann, Anne Cust

Melanoma is the third most common cancer in Australia. Clinical practice guidelines recommend that people at high risk of melanoma be identified and regularly monitored so that melanomas can be detected at an early stage, as morbidity is greater with higher risk of metastases when melanoma is detected later. Research conducted at Sydney Melanoma Diagnostic Centre, Sydney, found that regular monitoring using skin surveillance technologies was feasible and effective for managing people at high-risk of new primary melanomas.


We conducted a micro-costing study to determine the mean cost per patient for specialised surveillance in a hospital setting, a cost-effectiveness analysis using patient records and a population-based cohort study linked to cancer registry, Medicare Benefits Schedule (MBS) and hospital data, and finally a budget impact analysis to determine the number of eligible patients for specialised surveillance and health care budget implications.


Specialised surveillance was both less expensive and more effective than routine care, due to earlier detection of melanoma and a lower annual mean excision rate for suspicious lesions. The mean saving over 10 years was $6,828 (95% confidence interval (CI) $5,564-$8,092) per patient, and the mean quality-adjusted life year (QALY) gain was 0.31 (95% CI 0.27-0.35). Using a five-year time frame and assuming that all eligible patients (estimated at 18% of melanoma patients in Australia), were monitored using specialised surveillance, the total cost savings would be $30.6 million with a cumulative cost of $100.0 million for specialised surveillance.


Specialised surveillance subsidised through Medicare has the potential to lead to cost savings for the Australian health care system. To improve access to appropriate skin surveillance we will examine the replicability of our results in other settings, including primary care. Monitoring will be needed to observe if there is maintenance of efficacy in excision rates over time.

A real‐world investigation of resource use and costs of bariatric surgery in an Australian public hospital system based on Australia’s Activity Based Funding model
Julie A Campbell; Martin Hensher; Daniel Davies; Matthew Green; Barry Hagan; Ian Jordan; Alison Venn; Amanda Neil; Alexandr Kuzminov; Petr Otahal; Andrew J Palmer¹.

Introduction: Within the Australian public hospital setting, there are no studies that investigate resource use and unit-costs for bariatric surgery informed by the Council of Australian Government’s Independent Hospital Pricing Authority (IHPA) framework.


Methods: The retrospective observational study included patients waitlisted for primary bariatric surgery from 01January2008 to 31December2013. Resource use and unit cost data were extracted from administrative data routinely collected and clinically-coded according to guidelines within the Tasmanian Government’s Department of Health and Human Services. Episodes of care (EOC) were investigated for the fiscal years 0708 to 1516. Costs were expressed in constant dollars using the Government Final Consumption Expenditure on hospitals and nursing homes deflator. Sensitivity analyses on costs were conducted using other indicies and subgroup analyses.


Results: N=552 patients were waitlisted and n=107 underwent primary bariatric surgery in the public hospital system (n=91 laparoscopic adjustable gastric band (LAGB) and n=16 sleeve gastrectomy (SG)). Some patients’ surgery was contracted into the private system, or they opted for surgery elsewhere. For publicly surgically treated patients, over half had diabetes and/or cardio-vascular disease. Age at surgery for LAGB patients was mean (SD) 47.6 (11.5) and SG patients were a decade older. For LAGB patients, inpatient length of stay was 1.65 (0.86) days compared to SG patients of 3.8 (1.1) days. Inpatient costs for the primary surgical EOC were mean (SD) $9,851 (3,831) for LAGB and $14,409 (5,752) for SG. Secondary surgery for LAGB was mostly appliance related.


Discussion: This is the first study to investigate real world costs for bariatric surgery informed by the Australian IHPA Activity Based Funding framework. Resource/costs for publicly-waitlisted Tasmanian patients are in line with comparable national and international jurisdictions such as Canada.

Economic evaluation of dementia interventions: simplified approach to a complex social and economic problems?
Kim-Huong Nguyen, Tracy Comans, Colin Green

Background: Given the aging population and increasing healthcare and social costs associated with the treatment and caring for people with dementia, more efficient use of resources is critical. Economic evaluations have enabled researchers and policy makers to investigate the cost effectiveness of a wide range of dementia interventions.


Aim: To assess the state-of-the-art of health-economic modelling of dementia interventions though a comprehensive systematic review of modelled economic evaluations of early diagnosis, treatment and management interventions for people with dementia and their caregivers.


Method: A systematic research of the health care literature was undertaken to identify relevant studies. Inclusion criteria include: (a) interventions that target people with dementia and caregivers and (b) individual modelled economic evaluation (exclusion of reviews and systematic reviews). Searches were conducted between November 2016 to 30 April 2017.


Results: The search identified one modelled economic evaluation of an intervention for caregivers of people with dementia, 15 screening and early diagnosis interventions for people with dementia, and 46 studies evaluating dementia treatment, most of which were pharmacological products. Majority of the studies used decision-analytic models to represent dementia progression in terms of cognitive function. Most models did not account for caregivers but when they did, caregivers’ cost and quality of life were not modelled explicitly.


Conclusion: Most modelled economic evaluation studies follow narrowly defined disease pathways (cognition) with limited representation of caregivers, dynamics of dementia dyads and their interactions with the healthcare and social care systems. For a disease that currently has no cure, and active management with a’cocktail’ of pharmacological and non-pharmacological interventions is the key, these approaches fail to capture the complex pathway, thus social and economic consequences. Future research should give priority to collaborative efforts to develop and validate comprehensive approaches to health-economic modelling of dementia interventions.

Assessing the impact of paediatric hospitalisation: measuring the financial and productivity burden on the wider family network
Virginia Mumford, Melissa Baysari, Magdalena Raban, Johanna Westbrook

Objectives: The involvement of the wider family network in caring for children in hospital is rarely considered when conducting economic evaluations. This study addressed this gap by estimating the financial and productivity burden of a child’s hospital stay on parents, family and carers.


Design, Setting, and Participants: A survey of 225 parents of paediatric inpatients on nine wards (excluding intensive care, oncology wards, and Emergency Department) of a public paediatric teaching hospital, on two separate days.


Main outcome measures: Number of days taken off work to care for the child in hospital and to care for other dependents. Additional data included costs of travel, meals, accommodation and incidental expenses during the child’s stay. Demographic data included postcode (to assess travel distance), age of child, ward, and whether this was the first admission.


Results: Mean patient age was 6.5 years (SD 5.2), and mean length of stay (LoS) was 5.6 days (SD 12.0). The number of day patients in our sample (35.0%, 89/255) contributed to a median LoS to 2.0 days. On average, for each day in hospital, parents took 1.12 days off work, and spent 0.61 (SD.53) nights away from home with 91.7% of nights away either at the child’s bedside or in accommodation at the hospital. We estimated parents spent AUD89.20 per day on travel, and AUD36.02 on meals and accommodation.


Conclusions: These results demonstrate the considerable financial and time resources expended by families caring for a child in hospital, and can be used in evaluating healthcare interventions that affect length of stay in paediatrics.

Value based pricing to improve hospital quality and efficiency
Henry Cutler

Governments around the world are pursuing value based health care by tightening the relationship between funding and health care performance. Yet the success of financial incentives to improve health care quality and efficiency is mixed. Importantly, success is context specific, and relies on the design characteristics (although only weakly). Little is known about the extent to which they are cost effective relative to other means for meeting those objectives.


However, outcomes based funding models are being used in Australia, particularly in the private hospital sector. The Independent Hospital Pricing Authority (IHPA) is also exploring the potential to price for safety and quality, including’never events’, hospital acquired conditions, and avoidable hospital readmissions, while Queensland Health does not pay for six never events.


While these outcomes based funding models aim to incentive the avoidance of poor care, value is comprised of many additional components, including improved health, patient experience, and efficient use of care types (e.g., inpatient acute care versus hospital in the home).


The paper explores the use of value based pricing in hospital markets through a systematic literature review. The first objective is to examine the key design characteristics of value based hospital pricing. The second is to summarise components used to represent’value’, including clinical, patient experience, and efficient use of care types. The final objective is to summarise the success of value based pricing towards improved hospital efficiency and quality, and highlight unintended consequences.


The literature review results are placed in the context of the Australian public hospital environment and its shift towards measuring health outcomes. The paper concludes by exploring potential barriers that would need to be circumvented before a value based pricing model (using a broader definition of value) could be introduced.

The impact of incentives upon integrated care for patients with chronic conditions
Jodette Kotz

For people with a chronic condition, the development of an effective care plan is complicated by the segregation of service providers in Australia’s complex multi-layered health system. As with most complex systems, the incentive structure is a key driver of behaviour. Changes to the mix of incentives can produce desired results or unintended consequences. As such, there is considerable interest in the use of incentives to influence the provision of services and health outcomes. Understanding how the current suite of incentives drives health care provision is key to framing potential changes. This research explores the impact of incentives upon integration for patients with chronic conditions.


This research uses two in-depth case studies of health care policies: the impact of incentives created through the Intergovernmental Agreement on Federal Financial Funding Framework; and incentives deriving from policies developed by regional health service organisations. The studies were conducted through document review, key system informant interviews, and conceptual analysis.


The results indicate that interactions between the funding models applied at the macro, meso and micro levels influence the ability for providers to collaborate. Discrepancies exist between the extrinsic incentive structure and the agreed objectives, outcomes, roles and responsibilities contained within the policies relating to chronic disease, integration and patient centered care. This encourages various incentives to compete with each other, undermining the ability for service providers to integrate.


The lack of coherence in the incentive structures found could be inadvertent, but could also reflect ideological tensions between the Government’s desire to intervene to influence stakeholders (service providers or patients), and a trend towards deregulation. The paper finishes with a discussion around options to improve integration and patient centered care for people with chronic conditions through incentive design and proposes an alternate funding model.

Revisiting horizontal inequity of health care use: An analysis of regional variation in Australia
Mohammad Habibullah Pulok; Kees van Gool; Jane Hall

Achieving equity is a central policy objective of health care systems of many developed countries including Australia. Medicare, Australia’s tax-funded national health insurance system has been designed to provide universal health coverage to all Australians. It aims to ensure affordable and equitable delivery of health care services according to health need by removing financial barriers. The concentration index (CI) based horizontal inequity (HI) methodology is widely applied to study horizontal equity in health care. This paper uses data from recent Australian National Health Surveys to measure the extent of horizontal inequity and to examine the contributing factors of income-related inequity in health care use. We also explore the spatial dimension of horizontal inequity by analysing state-level variation in HI indices of health care service use.


Overall, our analysis shows that the horizontal equity in health care service use has become either pro-rich or equitable in Australia in recent times. HI estimates suggest that distribution of primary care service use is equitable or pro-poor but inequity in specialist service use is pro-rich. We also find the greatest pro-rich inequity in dental care. There is also evidence of state-level variation in pro-rich HI estimates of health care service use. Decomposition analysis further suggests that private health insurance, education and employment are the primary factors of the pro-rich inequity of health care service utilisation. Our study provides the first evidence on state-level variation in horizontal inequity of health care use. This paper presents new evidence on whether the horizontal equity principle of Medicare is achieved in the era of encouraging privatisation of health care funding. Despite the universal health insurance system in Australia, there is inequity in use of needed healthcare services, and it varies across states.

The association between continuity of care and screening mammography
Michael Wright

The association between continuity of care and emergency department attendance.


Continuity of care is considered a core component of high performing high performing primary health care systems, While international research suggests that increased personal continuity of care is associated with decreased emergency department attendance and decreased potentially preventable hospitalisations, most of this research is cross sectional and fails to consider the endogeneity of continuity of care in the demand for health services. This research seeks to understand whether these is an association between increased continuity of care and decreased emergency department presentation in the Australian context (characterised by unrestricted access to general practice and emergency departments), and whether this association holds for patients with continuity of care a general practice level (site continuity), as well as for continuity with an individual general practitioner (personal continuity). This research utilises data from the Australian Longitudinal Study on Women’s Health (ALSWH), a large longitudinal (n>50000) study of Australian women which began in 1996, with linkages to Medicare and State based- Emergency Department registries Results from this analysis reveal different emergency department attendance rates for women with site continuity and personal continuity, compared with those with no continuity, even after controlling for a rich set of patient covariates, as well as indicators of price and access within the ALSWH and Medicare data.

Portliness amidst Poverty: Evidence from India
Pushkar Maitra; Nidhiya Menon

We analyze patterns and correlates of excess weight of adults in India. We find that urban women are particularly at risk of being overweight or obese and that income or wealth, relative inequality, and lifestyle are strongly correlated with excess weight. Using panel data for women, we find that there is strong persistence in being overweight or obese – there are significant transitions into this but very little movement out of this category over time. Estimates of health impacts indicate that overweight or obese weight status is positively associated with the incidence of diabetes and blood pressure.

Title to come
Lisa Cameron, Diana Contreras Suarez, and Katy Cornwell

Indonesia has one of the highest Maternal Mortality Ratios (MMR) relative to other countries at a similar stage of development in the region. Using information from the population and village census we show that education, and socio-economic status more generally, have a strongly protective effect on maternal mortality. Given that there is great variation in both demographics, access to health services and MMRs across Indonesia, we decompose the driving differences between high and low performing regions in terms of maternal mortality ratios. Following a Blinder-Oaxaca decomposition method we find that MMR is 56% lower in high performing regions and 28% of the difference in maternal mortality is due to access to health services, in particular, hospitals and doctors. The challenge to reduce maternal mortality in Indonesia is to provide access to higher-level health services – hospitals and doctors – which are able to improve outcomes in the most difficult cases, for example, when surgery or blood transfusions are required. In contrast, the widespread availability of health centres and midwives has probably reduced maternal mortality as much as is possible.

Adult Child Labour Migration and Elderly Parent Health: Recent Evidence from Indonesian Panel Data
Alfiah Hasanah; Silvia Mendolia ; Oleg Yerokhin

This paper explores the impacts of adult child migration on the health of elderly parents left behind. Maternal and child health is a priority of health-related policy in most low- and middle-income countries, and there is a lack of evidence on the health of aging individuals, particularly in Indonesia. With increasing life expectancy and limited access to social security and social services for the elderly in this country, the consequences of the increasing out-migration of adult children for parent health is important to investigate. This study uses the Indonesia Family Life Survey (IFLS), and several indicators of health and outpatient care to estimate the impact of the labour out-migration of adult children on parental health status. The results show that the labour out-migration of adult children has a positive and significant association with the health status of the parent left behind. The findings of this study are consistent with the view that migration increases family resources and contributes to better health care for the family left behind.

Assessing Fiscal Space for Health in India: Empirical Evidence
Deepak Behera; Umakant Dash

The lower middle-income countries like India often struggle with higher out-of-pocket health expenditure and the lower share of public health expenditure, resulting in poor health care services and a huge burden on poor people and leads to poverty. The slower growth of public health expenditure has become a great concern for policy makers, therefore efforts have to be made to increase fiscal space for the health sector in these resource-poor countries. The empirical procedure of this study is divided into two parts. First, use an augmented fiscal space for health function to examine the relationship between public health expenditure and macroeconomic policy changes in India using Pesaran et al. (2001) ARDL bound testing approach for the period 1980-2014. Second, the causality between the variables is tested by employing the VECM Granger Causality Approach. The result shows that there is a negative relationship between domestic debt and public heath expenditure in both short and long run. On the other hand, fiscal deficit and tax revenue become the key factors of increasing public health expenditure in the long run. These results have policy implication for the realization of sustainable finance in the implication of universal health coverage in India by improving tax collection and enhance tax base. As a consequence, India would mitigate the negative impact of debt burden on health by improving its fiscal balance.

Heterogeneous Effects of Health Shocks in Developed Countries? Evidence from Australia
Asad Islam; Jaai Parasnis

Idiosyncratic shocks, such as health shocks, have been shown to have significant effects of income, consumption smoothing and asset accumulation in developing countries. However, less is known about how health shocks impact on individuals and households’ consumption and saving behaviour in developed countries. In this paper we examine how health shocks impact on households’ decision to save, and how different socio-economic and ethnic groups respond to health shocks in Australia. We find that health shocks are associated with a substantial and significant reduction in individual savings but not in household net worth. We do not find any substitution of labour supply by a partner in response to an individual’s health shocks. We also find evidence that negative health shocks are associated with an increase in receipts of public transfers and benefits in the following years. There is some evidence that the fall in savings is greater for the low-income individuals even if they are insured by public health system and unemployment benefits. Migrants experience a larger decline in saving compared to Australian-born individuals. Surprisingly, savings of individuals who have private health insurance are more affected by health shocks compared to individuals who do not have private health insurance, suggesting a role for selection into private health insurance.

Blood pressure and cholesterol level checks as dynamic interrelated screening examinations
Alexander Labeit, Abbi Kedir, Frank Peinemann

This study analysed the determinants of screening uptake for blood pressure and cholesterol level checks. Furthermore, it investigated the presence of possible spillover effects from one type of cardiovascular screening to another type of cardiovascular screening. A dynamic random effects bivariate panel probit model with initial conditions (Wooldridge-type estimator) was adopted for the estimation. The outcome variables were the participation in blood pressure and cholesterol level checks by individuals in a given year. The balanced panel sample of 21,138 observations was constructed from 1,626 individuals from the British Household Panel Survey (BHPS) between 1996 and 2008. The analysis showed the significance of past screening behaviour for both cardiovascular screening examinations. For both cardiovascular screening examinations state dependence exist. The study also shows a significant spillover effect of the cholesterol level check on the blood pressure check and vice versa. Also a poorer health status led to a higher uptake for both types of screening examinations. Changes in recommendations have to consider the fact that taking part in one type of cardiovascular screening examination can influence the decision to take part in the other type of cardiovascular screening examination.

Income‐based mandates on the demand for private health insurance and its dynamics: Early insights using Australian panel data
Terence C. Cheng and Ngoc T. A. Pham

We examine the effect of an income-based mandate on the demand for private health insurance (PHI) and its dynamics in Australia. The mandate, known as the Medicare Levy Surcharge, is a levy on taxable income that applies to individuals without PHI and whose incomes are above a certain threshold. To identify the effect of the mandate, we rely on a policy reform in 2008 where income thresholds were increased significantly. Using 2004-2013 data from the Household, Income and Labour Dynamics in Australia (HILDA) longitudinal survey, we estimate a series of static and dynamic models that account for unobserved effects, state dependence, and irregular panel data. Early results indicate that the mandate has a small and positive effect on the decision to purchase PHI. The magnitude of the estimated effect in our study is significantly smaller than those in previous studies that used cross-sectional data. We also find considerable state dependence in individuals’ decision to purchase PHI. The estimated effect of the mandate however does not differ with and without accounting for state dependence.

Perfect prediction and bias in fixed effects binary response panel models, with an application to the Hospital Readmissions Reduction Program
Johannes Kunz; Kevin Staub; Rainer Winkelmann

In short panels, fixed effects models for binary response models, such as logit and probit, are difficult to estimate by maximum likelihood. A prominent problem is the incidental parameters problem, where estimation of the individual-specific intercepts biases the coefficients of covariates. A second problem is that if there is no within-unit variation in the outcome, the maximum likelihood estimator for the fixed effects corresponding to that unit is not defined; a case of perfect prediction. As a consequence, estimates of the distribution of the fixed effects, which, for instance, are of interest to rank units, are biased, as are quantities that depend on the fixed effects, such as predictions and marginal effects. This paper addresses both these problems within a penalised likelihood approach. We show that an estimator due to Firth (1993, Biometrika 80(1), pp. 27-38), which modifies the score of the likelihood estimators, can be used to remove the first-order bias and ensures the finiteness of the estimates of the fixed effects, while other penalised likelihood estimators lack the latter property. Results from a simulation study indicate that the estimator has favourable small sample properties. Finally, the estimator is applied to study the unobserved heterogeneity underlying hospitals’ likelihood to face negative incentive payments as a penalty for high readmission rates, a policy introduced in 2012 as part of the Affordable Care Act.

Exploring the potential use of quality information when choosing between alternative public hospitals for elective surgery
Emma Olin, Yuanyuan Gu, Henry Cutler

Background: Australian governments are currently exploring the use of greater choice among public hospitals to empower patients, improve hospital quality and generate better health outcomes. While publically available hospital performance information is essential for patients to make an informed choice, there is limited information currently available within Australia.International research suggests hospital performance information can be considered complex by patients, and while the idea of publically available information is valued, it is not necessarily used by patients when choosing between alternative health care providers. There are several barriers in utilising performance information, including patients’ socio-economic status, health literacy and limited availability of information to patients.


Aim: To explore whether patients may have difficulties interpreting and using hospital performance information when choosing between alternative public hospitals for elective surgery, whether difficulties in making choice are impacted by socio-demographic characteristics, and whether patients will seek help when choosing between hospitals.


Methods: An online survey was undertaken with a sample of 1,000 Australians between 50 and 75 years of age. Stated difficulties in choosing between alternative hypothetical public hospitals within a discrete choice experiment was compared to several respondent characteristic variables, such as their ability and confidence in understanding health care information and advice (subjective health literacy), and the level of trust placed in alternative sources of performance information. Data were analysed using OLS and non-linear regression models to explore correlations.


Results: Respondents noted they had some difficulties when choosing between alternative hypothetical public hospitals. No hospital outperformed the other on all performance dimensions, requiring respondents to trade-off alternative performance dimensions. There was also variation in the approach to choosing, with some respondents considering all performance dimensions, while others using a more heuristic approach and considered only a subset when making their choice. Statistically significant correlations were found between difficulties in making choices and approaches to choosing, with respondent characteristics such as subjective health literacy, age, education and gender. Additional results suggest help from a GP when making choices between alternative public hospitals would be valued by respondents, particularly those with low subjective health literacy.


Discussion: For any pro-choice policy to drive quality improvements in Australian public hospitals, quality information must be understood and valued by patients when making a choice. This will ensure hospital and government managers receive appropriate signals on the demand for hospital care based on quality.Our findings indicate that older people and people with low subjective health literacy are likely to face significant barriers if asked to use performance information to choose between alternative public hospitals. This suggests there is a potential role for GPs or other health professionals to assist patients when choosing between alternative public hospitals if greater choice were introduced. Assistance would help people choose a hospital based on quality, thereby improving equity of access to better performing hospitals and providing a stronger signal to hospital and government managers to improve quality.

What is the Value of a Driver Licence? A contingent valuation study of Australian adults
Blake Angell

Background: how to incorporate social determinants of health into economic evaluations is an ongoing issue for the health economics field. This study investigates the monetary value that a cohort of Australian adults place on holding a driver licence as a means of examining the role that contingent valuation studies can play in this process.


Methodology: a contingent valuation study of 1,054 Australian adult licence holders (with an oversampling of Indigenous Australians) was carried out to derive the cohort’s willingness to pay (WTP) to avoid losing their driver licence for a period of one year. Interval regression analyses were undertaken to determine the association between a range of demographic and driving-related characteristics of respondents and their WTP valuations.


Results: mean WTP based on the base model was $2,290 to avoid losing a driver licence for a year (95% CI $2,156 – $2,431). WTP was significantly higher for respondents who drove multiple times a week ($396 higher WTP, p=0.012) than those who did not and who required a car for work compared to those who did not ($520 p=0.002). WTP increased with higher incomes and was greatest for those earning over $120,000 annually ($1,352 higher than those earning under $40,000 per year.

An international study of the preferences of patients, caregivers and health professionals for important outcomes in nephrology
Martin Howell; Kirsten Howard; Benedicte Sauutenet, Angela Ju; Andrea Viecelli, Germaine Wong; Jonathan C Craig; Allison Tong for the SONG Initiative Group

Patients and health professionals have different perspectives and preferences for health outcomes. Preferences also vary with age, experiences and cultural background.


Aim: To assess the relative importance of outcomes in transplantation, vascular access and fatigue in haemodialysis.


Method: In international surveys, patients and health professionals rated importance on a 9 point scale for 16 transplant, 12 vascular access and 11 fatigue outcomes. Preferences were elicited using Best-Worst Scaling tasks and estimated using mixed multinomial logit models with panel specification. Preference scores were adjusted to range from 1 (least) to 9 (most) important.


Results: Patients (n=607) and health professionals (1,124) from 51 countries participated. Preference for outcomes of varying consequence differed between and within patient and health professionals for most outcomes in transplantation, vascular access and fatigue. For example hospitalisation was less important for transplant and dialysis patients than health professionals (preference scores 1.2 [95%CI 0.94, 1.49], 2.14 [1.76, 2.51] for transplant and 4.75 [4.21, 5.28], 6.53 [6.20, 6.57] for vascular access) and death more important for health professionals (9.0:7.8 to 10.2) than for transplant patients (5.1:4.6 to 5.7). Differences within groups include’life participation’ in fatigue, most important for English-speaking patients (9.0:7.8 to 10.4), for Spanish patients’dialysis fatigue’ was most important (9.0:7.0 to 11.0). In Chinese, Malay and English surveys health professionals had different preferences for hospitalisation, bleeding, oedema, pain and maturation. There was poor agreement between ratings and preferences due to rating ceiling effects.


Conclusion: The BWS enabled preferences of patients and health professionals from different cultural and linguistic backgrounds to be elicited. Surveys revealed important differences not evident from Likert rating scales.

A fine balance: Hospital decision‐maker’s preferences for funding of a new treatment on the hospital formulary
Kim K Hamrosi; Simon Fifer; Kylie Earle  

Background: Decisions by the Drugs and Therapeutic Committee (DTC) or its equivalent to fund new medicines on the hospital formulary are complex and require trade-offs between a variety of factors. These include safety, efficacy and cost-effectiveness compared with current treatment options. This study aimed to understand hospital decision makers (HDMs) stated preferences for the treatment of hyperkalaemia by valuing the specific attributes of new treatments to the relevant comparator.


Methods: HDMs (n=60) from both public and private hospitals in Australia involved in the DTC or equivalent and/or involved in applications to the hospital formulary were recruited through a specialist healthcare panel to complete an online survey involving a discrete choice experiment (DCE). The initial stage involved qualitative interviews (n=6) to inform the design of the survey. In the DCE scenarios HDMs were asked to trade-off the following attributes: frequency and mode of administration, onset of action, side effects, drug interactions, dietary restrictions, resource use and cost. Latent class models were used to assess the relative priority HDMs placed on different attributes and estimate their willingness to pay for new treatments.


Results: Analysis revealed heterogeneity in HDMs preferences linked to hospital funding models and primary clinical role. Further investigation of funding decisions indicated competing considerations of access, efficacy and cost-effectiveness.

Conclusion: The BWS enabled preferences of patients and health professionals from different cultural and linguistic backgrounds to be elicited. Surveys revealed important differences not evident from Likert rating scales.

Projections of economic impacts of early retirement in informal carers: Results from a microsimulation model Care&WorkMOD
Rupendra Shrestha; Deborah Schofield; Michelle Cunich; Simon Kelly; Robert Tanton; Megan Passey; Lennert Veerman

The need for informal care is projected to increase significantly due to an ageing population and the projected increase in the number of children with a disability. Providing informal care can have an impact on the capability of informal carers to maintain employment and thus require them to leave the labour force early. Early retirement is a significant economic burden both to informal carers in terms of lost income and savings; and to the government in terms of lost taxation revenue and increased welfare payments.


We have developed a microsimulation model, Care&WorkMOD, to project the long-term economic costs up to 2030 of early retirement of informal carers. The base population of Care&WorkMOD is based on the Australian Bureau of Statistics 2003, 2009 and 2012 Surveys of Disability, Ageing and Carers. Population and the labour force participation projections from the 2015 Intergenerational Report and the projected primary carers and the projected estimates of income, taxation, income support payments, savings and superannuation from microsimulation models APPSIM and STINMOD were synthetically matched with the base population to project forward the economic impacts of early retirement of informal carers.


It was estimated that about 106,000 people aged 15 to 64 years old would leave the labour force prematurely to provide informal care in 2015, which was estimated to increase to 127,000 by 2030. The total national economic impacts of this lost labour force due to informal caring were estimated at $3.6 billion in 2015, increasing to $5.3 billion in 2030 in lost incomes for informal carers annually.


These results highlight the need for effective prevention or treatment of illness and implementing targeted programs that increase the labour force participation of carers in order to reduce negative economic consquences of caring for families and the government.

Needs‐based Health workforce and services planning for child and adolescent mental health services
Leonie Segal, Gareth Furber, Sophie Guy.

Introduction: It is a principle of Medicare that access to health care should reflect need not capacity to pay and supply should be driven by efficacy and cost-effectiveness in meeting need. But, there are few published needs-based health services/workforce planning studies.


Aim: Apply needs-based workforce and services planning to child and adolescent mental health services in South Australia – chosen because off the direct impact on mental wellbeing, but also on physical health, social and economic outcomes and adult mental illness. In addition, survey data suggests major unmet need and under-servicing.

Methods: A comprehensive needs analysis was conducted to determine the extent of psychological distress in children from infancy to age 18, using the Longitudinal Survey of Australian Children and the ABS Young Minds Matter survey. Best practice was described in terms of clinical input (sessions x time x competencies) at each stage of the clinical pathway, drawing on the literature and clinical panels. Total regional workforce FTE was calculated as the product of these estimates and compared with current service delivery.

Results. Very high levels of psychological distress indicating clinical need were identified in children from infancy through to age 15, of 3-14% and were almost always associated with high levels of concurrent family adversity (family violence, parental mental illness/addiction, financial hardship, other family stressors, parental separation). The FTE required to address extreme psychological distress in children and adolescents was estimated at >3 times current service provision.

Discussion: Needs-based workforce and services planning is rarely undertaken but is critical if health services are to meet the health needs of populations and not entrench historic inequalities. Our findings mean that child and adolescent mental health services and the skilled workforce need to be considerably expanded to redress major under-servicing and the serious health social and economic consequences of this.

The subjective wellbeing of informal carers: Evidence from Australia
Azadeh Abbasi-Shavazi

Informal carers provide the majority of services required for the care of the disabled, chronically ill and frail aged in Australia. The health impacts on the carers are one of the indirect costs that need to be considered when designing long-term care policies. Using 14 waves of recent nationally representative longitudinal data from Australia, this paper investigates the effect of informal caregiving on subjective wellbeing and quality of life measures of informal caregivers. The effects of exposure to- and caring for a member with a disability in the household are differentiated and the estimates are reported from individual and household fixed effect models. After controlling for various confounding factors, statistically significant impacts of informal care on carer’s wellbeing measures are examined. Heterogeneous effects are reported for different subgroups. At the extensive margin, negative effects are mainly driven from the female sample. While both employed and non-employed carers show deterioration in well-being measures when taking up a caring role, the negative effect is only observed from the employed sample of caregivers on the intensive margin. Implications for the improvement of the wellbeing of the informal carers are discussed.

Language efficiency and psychological wellbeing: new evidence from immigrants in Australia
Anthony Niu; Hee-Seung Yang

Australia is one of the major destination countries for immigrants. As of 2016, around 30% of Australian population were born overseas. Over the last decade, a number of economics studies have found that English proficiency is strongly (and positively) associated with Australian immigrants’ socioeconomic and physical health outcomes. This study aims to progress the literature by examining the impacts of English ability on immigrants’ mental health status and life satisfaction. Using HILDA panel 2001 to 2015, the exogenous variation in English speaking skills is instrumented by an interaction term between immigrant’s age at arrival and original country of birth. Our main results show that English proficiency strongly improves immigrants’ mental health and life satisfaction (particularly the satisfaction on health, employment opportunity, neighbour you live, and safety). These strong and positive impacts may be driven by a wide range of intermediate channels, including education, physical health status, health behaviour, access to health services, and social capital. Further, stronger effects of English ability are found in the subgroups of male, low-educated and older immigrants who have been living in Australia for a long time (over 15 years).

Life satisfaction, QALYs, and the monetary value of health
Li Huang; Paul Frijters; Kim Dalziel; Philip Clarke

The monetary value of a quality-adjusted life-year (QALY) is frequently used to assess the benefit of health interventions, and subsequently to inform funding decisions. However, there is little consensus on methods for estimation of this monetary value. We propose to use life satisfaction as an indicator of’experienced utility’, and estimate the dollar equivalent value of a QALY using disposable income instrumented by financial worsening events. Using the Household, Income and Labour Dynamics in Australia survey, we estimate that individual’s willingness to pay for one QALY is approximately A$42,000-A$67,000, and the willingness to pay for not having a long-term health condition is approximately A$2,000 per year holding health-related quality of life constant. Give that the willingness to pay estimates are derived based on population-level information and a wellbeing measurement of life satisfaction, the approach has the advantage of being socially inclusive and recognizes the significant meaning of people’s subjective opinions. Also, the method estimates a wiliness to pay per QALY that is country-specific which could be particularly useful for nations where QALY thresholds are not yet established.

The health‐related quality of life of caregivers of children with intellectual disability
Sheena Arora, Stephen Goodall, Rosalie Viney, Stewart Einfeld

Introduction: This research produces utility values for caregivers of a child with intellectual disability (ID) across comorbid diagnostic groups. The second aim of this study is to determine the risk factors associated with poorer health-related quality of life (HRQoL) in this population. By determining the risk factors associated with poorer HRQoL, services can be better targeted to provide support to those most in need.


Methods: Caregivers of a child with ID aged between two and 12 years old were asked to describe their HRQoL using the EQ-5D-5L measure, their dependent child’s level of behavioural and emotional difficulties and answer a series of demographic questions.


Results: Of the total sample of 634 participants, 604 participants completed all five questions of the EQ-5D-5L. The mean EQ-5D-5L score of caregivers was 0.80 (95%CI: 0.79,0.82). Caregivers of children with autism spectrum disorders (ASDs) reported the lowest HRQoL (0.77) of the included comorbid diagnostic groups. An individual’s perception of their level of social support and the dependent child’s degree of behavioural and emotional problems were statistically significant predictors of caregiver HRQoL. In further models exploring the mechanism of this relationship it was found that the presence of ASD is a statistically significant negative predictor of caregiver HRQoL.


Conclusions: This is the first study to produce utility values for caregivers of children with ID. The utility values can be used to compare health states and can be used to inform comparative cost-effectiveness analyses. The results show that this population has a lower HRQoL than the age-equivalent general population. The regression analyses support the broader literature that a child’s degree of behavioural and emotional problems has a significant effect on caregiver wellbeing. This has important policy implications, highlighting the potential for policy interventions that target behavioural and emotional problems to improve outcomes for caregivers.

Can self‐rated health be used as a measure for global health?
Xinyang Hua; Thomas Lung; Mark Woodward; John Chalmers; Philip Clarke

Objective: To explore whether the predictive power of self-rated health on mortality risk is different across regions in the world.


Methods: This study is based on the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial and its post-trial observational study. 11140 patients with diabetes were followed up with a median of 10 years. A linear regression model was fitted first to estimate the effect of a range of clinical risk factors and region (Asia, Eastern Europe, Established Market Economies) on self-reported health, which was measured by the EuroQol group’s visual analog scale (VAS). A Cox regression model was used to estimate the predictive power of self-reported health on mortality risk during follow-up. Interaction terms between VAS and region were added to the Cox regression to assess whether the predictive power of VAS on mortality is different across regions.


Results: After controlling for other risk factors, compared to people in Established Market Economies, people in Asia report a higher level of self-reported heath, while people in Eastern Europe report a lower level of self-reported health. VAS has different predictive power on mortality across regions, a 10-point higher of VAS score was associated with 13% (95% CI:10-16) lower risk of mortality in Established Market Economies, 23% (95% CI:19-27) in Asia and 8% (95% CI:2-13) in Eastern Europe.


Conclusion: People in different regions across the world evaluate their health differently with respect to VAS. Adjustment should be made before directly comparing self-rated health across regions.

Does an increased supply of doctors improve population health?
Hugh Gravelle; Jinhu Li; Anthony Scott; Leticia Xander Russo

The impact of an increasing supply of doctors on population health is important for decisions on how many additional doctors are required. Using unique Australian data sets, we examine whether an increased doctor supply and hence higher competition will improve population health, and whether increases in the supply of GPs or specialists have differential effects.


We use individual data from the Household, Income and Labour Dynamics in Australia (HILDA) Survey, an ongoing panel data survey that follows over 19,000 individuals since 2001. The confidential version of the data has information at SLA and postcode level. The HILDA data will be matched at small area level to data on the number of GPs and specialists from the AMPCo data on all qualified doctors in Australia. The AMPCo data are provided as a snapshot in January and May each year since 2008 and include the work address of doctors. An eight year linked panel of HILDA and AMPCo data from 2008 to 2015 will be constructed and used in the analysis.


Panel data methods with individual and area fixed effects are used to control for both individual and area-level unobservables that influence both health status and supply conditions. Following Aakvik and Holmas (2006) dynamic panel data models will be used to account for the persistence of health status over time, using fixed effects, and lags can be used as instruments for GP and specialist supply. We will address potential bias due to mobility of individuals by using spatial lags model (Mobley et al., 2009) and include the number of GPs and specialists in adjacent areas as covariates. Our preliminary results indicate that an increased supply of GPs and hence higher competition does lead to improved health of the population.

Doctors with borders: The welfare effect of foreign doctor entry restrictions
David Byrne; Susan J. Mendez; Peter Sivey

The location decision of general practitioners (GPs) is a major determinant of the geographic distribution of the medical workforce. GPs location choices in turn have an impact on competition, access to healthcare, and health outcomes across markets. In this project, we study GP competition, supply-side entry restrictions, and unmet demand for care across areas.


In Australia, GPs who are overseas trained doctors or are foreign graduates of an accredited medical school are required to work in a district of workforce shortage for up to ten years. Foreign doctor entry restrictions protect locally trained GPs, but also limits GP competition. We evaluate how these restrictions affect equilibrium market structure and the supply of GPs in urban and regional markets.


To this end, we develop a new structural econometric model of strategic GP choice. Estimation exploits variation across time in underserved areas to estimate GPs fixed costs of relocating, which are fundamental to their market entry decisions. Our model provides a framework that allows the construction of counterfactual policy simulations, thereby allowing us to quantify the effect of regulation that works towards reducing imbalances in the market. Our data comes from the Australasian Medical Publishing Company (AMPCo) on the population of all doctors in Australian and from the Medicine in Australia: Balancing Employment and Life (MABEL) survey.

Hospital quality report cards: quality competition and patient selection
Yijuan Chen; Peter Sivey

Hospital report card policies involve governments publishing information about hospital quality. Such policies have become increasingly popular in many countries and often aim to improve hospital quality through some competitive process.


Previous empirical literature lacks a theoretical framework for analysing the effects of report cards. We model a report card policy in a market where two hospitals compete for patients on quality under regulated prices. The report card policy improves the accuracy of the quality signal observed by patients. Hospitals may improve their published quality scores by costly quality improvement or by selecting healthier patients to treat. We show that increasing information (report cards) always increases quality and only sometimes induces selection. Our welfare analysis shows that there will often be a corner solution for the welfare maximum at the point where increasing information starts to cause selection. We interpret this corner solution to show that report cards are more likely to reduce welfare when the risk adjustment of quality scores is poor, and where the regulated prices received by hospitals do not reflect patients’ heterogeneous costs of treatment.

Cream skimming, hospital transfers and capacity pressure
Terence Cheng; Ou Yang; Jongsay Yong

This paper investigates cream skimming behaviour by examining hospital transfers in a mixed public-private hospital system. Previous studies have suggested that the observed pattern of transfers between public and private hospitals, while consistent with cream skimming, could also reflect the pattern of specialisation of private and public hospitals. This paper reconsiders the issue by examining the pattern of transfers when hospitals were facing capacity pressure, which we argue is a plausible identification of cream skimming. We make use of 12 years of hospital administrative data from the state of Victoria, Australia. The data were divided into two subsamples according to whether the patient was initially admitted as public or private patients. For each subsample we estimate the probability of transfers using linear probability fixed effects and logistic equation estimation. The main findings are that, for patients initially admitted into the private setting, the transfer probability of complex and severe patients dramatically increased during times of capacity pressure, whereas this pattern was not observed for patients initially admitted into the public sector.

Economic Evaluation of Deep Brain Stimulation for Patients with Tourette’s Syndrome: An Initial Exploration
Thi Hai Tho Dang; David Rowell; Jacki Liddle; Terry Coyne; Peter Silburn; Luke Connelly

Background. Tourette’s syndrome (TS) is a neuropsychiatric movement disorder with childhood onset. Symptoms, which include involuntary tics, vocalizations and coprolalia, can adversely affect health-related quality of life. Severe TS that is refractory to pharmaceutical management, can now been treated with deep brain stimulation (DBS) with promising clinical outcomes. However, no economic evaluation has been published.


Methods. A cost-utility analysis is undertaken. Data generated by 17 Australian patients receiving DBS were analysed. Clinical indices for tic severity, depression, and age were converted into QALYs using published standardized coefficients obtained from a representative sample of 200 German outpatients. Direct medical costs for DBS and the alternative best medical treatment (BMT), and BMT health utilities were sourced from the literature. The incremental cost effectiveness ratio (ICER) was estimated using a Markov model, with a 10-year time horizon and different discount rate for costs and utilities. Deterministic and probabilistic sensitivity analyses were applied to test the model robustness.


Results. Discounted direct costs for DBS and BMT were US$127,967 and US$24,724, respectively. DBS increased health utilities from 0.51 to 0.82. The ICER was US$33,736 per QALY, which is less than the approved threshold of US$50,000. The model is sensitive to variations in utility gains and discount rate for effects. DBS was cost-effective in 80% of the trials.


Conclusions. Our initial exploration suggests DBS is a cost-effective treatment for severe TS. The principal limitations of the analysis were, a reliance on imputed utilities rather than direct measurement, a small sample size and exclusion of indirect costs. Future research should consider the administration of a health-related quality of life instrument to a larger sample of TS patients, pre- and post-DBS, to elicit a more accurate estimate of QALY increases.

Effectiveness of Post‐conflict Development Intervention on Maternal Health Care Utilization
Muhammad Badiuzzaman, Syed Mansoob Murshed and Matthias Rieger

We evaluate the effectiveness of a post-conflict development programme on maternal health-care utilization in the Chittagong Hill Tracts of Bangladesh. Our work varies from conventional impact evaluation studies because of the inclusion of two post-conflict risks: the household’s actual experience of violence and subjective perceptions about violence as key determinants of programme effectiveness. Following the difference-in-difference estimator method this study establishes that the post-conflict development programme undertaken by Chittagong Hill Tracts Development Facility of the United Nations Development Programme was successful in improving maternal health-care utilization. Despite this, household experiences of violent conflict, and perceptions of insecurity lower maternal health-care utilization. The effectiveness of the programme would have been greater in the absence of violence, although the programme may have mitigated some experiences of past violence.

Benchmarks for Quality Adjusted Life Expectancy for Australia, China, the United Kingdom and the United States of America
Andrew J. Palmer; Barbara de Graaf; Hasnat Ahmad; Lei Si.

Unlike life expectancy, for which age-and sex-dependent national life tables are regularly generated, no benchmarks exist against which to compare results of modelled projections of quality-adjusted life years (QALYs) to general population norms. We generated a set of benchmark values for age- and sex-dependent QALYs for the general populations of Australia, China, UK and the USA.


A 2-state Markov model was developed simulating subjects moving from “alive” to “dead” in annual cycles. Annual age- and sex-specific probabilities of all-cause mortality were taken from country-specific life tables, combined with general population country-specific age- and sex-specific health state utilities (HSUs) obtained using the EQ-5D-3L. Probabilistic sensitivity analysis (sampling from distributions around HSUs) was performed. Internal validation was performed by comparing life expectancies generated by the model with those reported in life tables. QALYs were estimated for age- and sex-specific cohorts in each country. A range of annual discount rates were applied.


The model was internally valid, with a correlation coefficient of 1.00 for model predictions versus reported life expectancies. For 18-year old Australian males, mean (95% confidence interval) projected QALYs ranged from 57.1 (55.7-58.6) to 17.5 (17.0-17.9) for discount rates 0% and 5% respectively. Eighteen year old females were projected to have 60.4 (59.2-61.8) and 17.6 (17.3-18.0) QALYs (discounted at 0% and 5% respectively).


We have generated benchmark age- and sex-specific QALY tables using a range of discount rates for 4 different country-specific settings using a validated model. These results will be useful for health economists when quantifying QALYs lost due to a particular disease compared to the general population.

Rethinking the 0 ‐ 1 Utility Scale
Tracy Comans

Research has highlighted inherent issues with the QALY measure. It is known to be inconsistent and unreliable. Furthermore, the work of Kahneman and Tversky highlighted numerous irrationalities present in decision making that undermine the assumptions of Von Neumann-Morgenstern utility. In 1972, Torrance wrote of a health utility index that:  An adequate scale might range from 0 for death (with negative values assigned to fates “worse than death,.. to 1 for good health ¦ p119 Health Index for Program Evaluation HSR


In this paper, I argue that the maxim of anchoring the utility scale on the values of 0 (death) and 1 (full health) is entirely arbitrary and illogical. I argue that this assumption generates inconsistent utility values, particularly for negative values and that improvement could be made by anchoring to the worst health state. Estimation of the utility of a health state should be done using an ordinal method consistent with general utility theory.

Should oral contraceptives be available over‐the‐counter?
Mutsa Gumbie; Bonny Parkinson; Henry Cutler

Despite the availability of many different forms of contraceptives, almost one half of all pregnancies in Australia are unplanned. Unplanned pregnancies may have significant effects on a woman’s life. One strategy of reducing unintended pregnancies would be to improve access to oral contraceptive pills (OCPs). In Australia, OCPs are currently available by prescription only (Rx), however they have recently been recommended to be down scheduled from Rx to over-the-counter (OTC) in New Zealand pharmacies. Down scheduling OCPs would encourage some patients to switch from less effective methods, such as the rhythm method, to OCPs, and reduce the need for GP visits to simply obtain prescriptions. However, some patients may switch from condoms to OCPs, thus increasing their risk of sexually transmitted diseases. The aim of this study is to estimate the cost-effectiveness of down scheduling OCPs to be available OTC in Australia.


A Markov model with a one year time frame was used to estimate the impact of down scheduling OCPs on the rate of pregnancies, sexually transmitted diseases and adverse events. The type of contraceptive used and fertility history by age, before down scheduling the OCP, was obtained from the 2015 Household Income and Labour Dynamics in Australia (HILDA) survey (Wave 15, Topic on Children and Fertility). The type of contraceptive used after down scheduling was based on a stated preference survey. The impact of contraceptive choice on the rate of pregnancies, sexually transmitted diseases, and adverse events was based on a variety of published sources. The results were reported in terms of cost per QALYs gained. It was found that down scheduling the contraceptive pill was likely to be considered cost-effective, and the results most sensitive to the efficacy of the OCP.

Using health‐related quality of life scores as predictor of outcomes in lower limb arthroplasty patients
Michelle Tew; Philip Clarke; Kim Dalziel; Michelle Dowsey; Peter Choong

Patient reported outcomes such as health-related quality of life (HRQL) are increasingly used in clinical research and in general medical practice to assess and quantify patient outcomes. Demonstrating that they can be used to independently predict mortality, need for revisions or surgery-related complications can add clinical value in informing the potential effectiveness and cost-effectiveness of joint replacement surgeries. Existing literature have showed that index scores derived from the EQ-5D can be used to independently predict the risk of mortality and potential complications in type 2 diabetic patients and in patients with coronary disease, mortality outcomes were found to be associated with scores from disease-specific health status measures.


The St. Vincent’s Melbourne Arthroplasty Outcomes Registry (SMART) is a clinical registry which collects both clinical and patient reported outcomes in patients who have undergone elective lower limb arthroplasty and has collected data from about 10,000 patients since 1998. The registry contains information regarding patient demographics (age, sex, socio-economic status), existing co-morbidities, operative and post-operative complications, death and patient reported outcomes (WOMAC and SF-12/VR-12). Patients undergoing these surgeries are generally older patients with considerable co-morbidities hence their competing risk of death and potential surgery-related complications can be high. This will be taken into account in the analysis. Using data from the SMART registry, this research aims to use various statistical models such as multivariate Cox proportional hazard models will be used to assess if changes in HRQL scores are independently predictive of outcomes such as the need for revision(s), surgery-related complications and death. Results will be used to build a risk assessment tool that will aid clinician decision making in ensuring optimal patient outcomes by identifying patients most likely to benefit from lower limb arthroplasties.

Influence of Socio‐economic location‐ and factors on diet and physical activity among overweight/obese pregnant mothers
Sharmina AHMED; Jodie M DODD; Andrea R DEUSSEN; Wendy UMBERGER

This study examined the relationship between socio-economic status and healthy eating- and exercise habits among obese/overweight pregnant women. This post hoc analysis of the LIMIT Randomized Controlled Trial, a lifestyle intervention for overweight and obese pregnant women conducted in South Australia, included xxx women from the control group.870. We report food consumption patterns in two ways derived from the self-reported Harvard Semi-quantitative food frequency questionnaire: 1. Healthy Eating Index (HEI); 2. Usual weekly intake of different food groups. Women completed the SQAUSH questionnaire and this was used to estimate physical activity. The participant’s residential postcode at the time of trial entry was used to estimate socio economic disadvantage as measured by the ABS’s SEIFA index of Socio-economic Disadvantage for postcodes. Demographic factors such as age, smoking behaviour and race were included in the analysis and all analyses were adjusted for hospital location and year of trial entry. Our results showed that women from postcodes with the highest level of disadvantage had lower HEI scores indicating poorer diet quality. HEI scores increased as SEIFA index for disadvantage for postcodes decreased. Among different food groups, Obese/overweight pregnant women from least disadvantaged suburbs consumed more cereal/bread and dairy products compared with women from more disadvantaged suburbs, however, they also consumed more alcohol. Physical activity was similar for all women regardless of their residential postcode.


These results provide important baseline information to further investigate local availability of different food items and identification of food deserts in metropolitan and non-metropolitan areas of Australia.

Prediction of Body Mass Index for the Adult Population of Australia 2015‐2050: Age‐Cohort Trend Analysis and Variance Modelling
King Wa Tam, Michelle Haby, Anna Peeters, Lennert Veerman

An upward trend in body mass index (BMI) has been observed in the Australian adult population for over three decades. The objective of this paper is to forecast the likely future of the obesity epidemic while taking into account the increasingly right-skewed distribution of BMI.


Population-based cross-sectional datasets from 1980 to 2015 are used in the analysis. BMI is calculated from measured weight and height for adults aged 18 years and older who were not pregnant at the time of evaluation. Results were compared to previous estimates. A linear regression model is used to estimate BMI separately for each gender, with age and cohort as independent variables. A multi-step approach is used to predict the shape of the future BMI distribution, which involved fitting the log-normal distribution to BMI for gender and five-year age-specific stratums, and modelling the mean BMI (location) as a function of gender, age, and the standard deviation in BMI (scale).


The age-adjusted trend in BMI is projected to be 2.47% increase per decade for males and 3.18% increase per decade for females. On current trends, the average BMI for women will become higher than that for men from the year 2055. The prevalence of adult obesity is projected to be 35% in 2025, 40% in 2035, and 48% in 2050.


There is evidence for a slowing of the increase for both genders. Further research is required to better understand how deceleration in the trend will affect the future course of obesity prevalence in Australia. Continual research and policy efforts will be crucial to halt the obesity “epidemic” and potentially reverse it, as average BMI continues to trend upwards and its distribution is becoming more right-skewed, putting further economic strain on Australia’s health care system.

These results provide important baseline information to further investigate local availability of different food items and identification of food deserts in metropolitan and non-metropolitan areas of Australia.

Insights from a Member of the MBS Reviews Task Force
Adam Elshaug


Kees Van Gool



Are Eating Disorder Prevention and Treatment Interventions Cost‐effective? A systematic review
Long Khanh Dao Le

Eating disorders (EDs) are prevalent conditions associated with substantial economic and social burden. This aim of the current study is to undertake a systematic review which have evaluated the cost-effectiveness of both preventive and treatment interventions for ED.


Electronic databases (including the Cochrane Controlled Trial Register, MEDLINE, PsychInfo, Academic Search Complete, Global Health, CINAHL complete, Health Business Elite, Econlit, Health Policy Reference Center, and ERIC) were searched for published economic evaluation (EE) of ED prevention and treatment including papers published up to Jan 2017. The quality of included studies was appraised by the CHEERS checklist.


Thirteen studies met the review inclusion criteria as full EEs, half of these have been published since 2011. The studies included three modelled studies focused on prevention, two trial-based and one modelled study for anorexia nervosa treatment, three trial-based studies for bulimia nervosa treatment, with the three remaining studies targeting binge-ED or non-specific ED treatment. Most of studies were of reasonable quality (scoring over 60% on the CHEERS checklists). ED interventions was mainly dominant or more effective and more costly compared to comparators, but some results did not reach statistical significance. Insufficient evidence of long-term cost-effectiveness (e.g. over 2 years) was found.


Economic evaluations of EDs are increasing in both quantity and quality. Given the lack of comparability across studies, no firm conclusion can be drawn with regards to which interventions provide definitive value-for-money. Further research with improved methodology is required.

Cost‐effectiveness of community based childhood obesity prevention interventions in Australia
Jaithri Ananthapavan; Phuong Nguyen; Gary Sacks; Rohan Sweeney; Boyd Swinburn; Victoria Brown; Anita Lal; Marjory Moodie.

Objectives: To examine, from a societal perspective, the cost-effectiveness of community based interventions (CBI) – defined as a program of community-level strategies to promote healthy eating and physical activity for Australian children aged 5-18 years.


Methods: The effectiveness of CBI, measured by mean difference in body mass index (BMI) z-scores, was determined by undertaking a systematic review and subsequent meta-analysis of ten quasi-experimental trials conducted between 1990 and 2016 using a random effects model. Based on the literature, a generic CBI comprised of three school-based physical activity and four nutrition components, plus wider community actions, was costed. Several programs were costed to estimate the average cost of generic program components (2010 Australian dollars).


A multiple cohort Markov model that simulates diseases associated with overweight and obesity was used to estimate the long term health benefits and associated cost offsets. Outcomes were measured as BMI units saved and Health-Adjusted Life Years (HALYs) averted over the lifetime of the target population. Monte-Carlo simulation was used to estimate the Incremental Cost-Effectiveness Ratios (ICER) with 95% uncertainty intervals (UI). Scenario analyses tested variations in program intensity, target populations and intervention effect decay.


Results: The estimated net costs of implementing CBI across all Local Government Areas in Australia was $550M ($220M; $866M) (intervention costs $1.00B ($0.94B; $1.06B), cost offsets $453M ($781M; -$148M)) over 3 years. This resulted in savings of 51,863 HALYs over the lifetime of the cohort. The median ICER was $15,476 per HALY saved ($2,491; $49,016), with a 98% probability of being cost-effective at a willingness to pay threshold of $50,000 per HALY.


Conclusion: CBI remained cost-effective under most scenarios tested. This evaluation is part of a priority setting study of obesity prevention interventions. The relative cost-effectiveness of CBI can be assessed against other strategies when they become available.

The economic and health burden of disease caused by group A streptococcus in Australia and New Zealand
Jeffry Cannon, Susan Jack, Jane Zhang, Yue Wu, Michael Baker, Elizabeth Geelhoed, John Fraser, Jonathan Carapetis

Background: Group A streptococcus (GAS) causes a high burden of severe invasive and immune-mediated diseases as well as superficial infections. The World Health Organization has highlighted that a vaccine could offer major health and economic benefits, however, these effects have never been studied. We aimed to establish the potential benefits of preventing GAS infections in Australia and New Zealand by estimating the economic and health burden of GAS diseases.


Methods: We synthesised and modelled over 65 data sources including; nationally-representative survey and administrative data on healthcare episodes; pathology and observational studies of disease outcomes; public reimbursement data and costing studies; and disability weightings from the Global Burden of Disease. Outcomes included estimates of the average annual incidence of healthcare episodes, direct healthcare cost, and disability-adjusted life years (DALYs) lost, in total and stratified by disease type and age.


Results: GAS affects an estimated 3.4% of the Australian population each year, with an associated direct cost of AUD 183.2 million (AUD 8.20 per person), and health burden of 23,334 DALYs (104.4 per 100,000 population). For New Zealand, an estimated 1.5% of the population is affected each year, with a direct cost of NZD 29.2 million (NZD 6.89 per person), and health burden of 2,373 (55.9 per 100,000 population) DALYs. Throat and skin infections were the most commonly presenting healthcare episodes, however cellulitis was the most substantial contributor to the total direct cost and health burden of GAS disease.


Conclusions: Preventing GAS disease, particularly cellulitis, would have substantial economic and health benefits.

A Health Economic Analysis of Stopping TNF‐Inhibitor Treatment in Rheumatoid Arthritis Patients in Remission or Low Disease Activity: results from the POET study
An Tran-Duy, Marjan Ghiti Mogahdam, Martijn AH Oude Voshaar, Harald E Vonkeman, Annelies Boonen, Philip Clarke, Geoff McColl, Peter M ten Klooster, TR Zijlstra, Willem F. Lems, N Riyazi, E.N. Griep, JMW Hazes, Robert Landewé, Hein J. Bernelot Moens, Piet L.C.M. van Riel, Mart van de Laar , Jansen TL; Dutch National POET Collaboration

Objective: To evaluate, from a societal perspective, the one-year trial-based cost-utility of withdrawing tumor necrosis factor inhibitors (TNFis) in rheumatoid arthritis (RA) patients with longstanding stable disease using data of the recently completed Potential Optimalisation of Expediency and Effectiveness of TNFis (POET) randomized trial.


Methods: Incurred healthcare costs and paid productivity loss were assessed at each study visit. Health utilities were assessed using the EQ5D questionnaire, and effectiveness as the number of flares. Cost-utility analysis was performed using the non-parametric bootstrapping method and a cost-effectiveness acceptability curve was constructed using the net-monetary benefit framework.


Results: 531 patients were randomized to the Stop Group and 186 patients to the Continue Group. Stopping TNF is resulted in a mean yearly cost saving of €7,132 (95% CI, [€6,069, €8,250]) and was associated with a mean loss of quality adjusted life years (QALYs) of 0.02 (95% CI, [0.002, 0.040]). Mean saved cost [95% CI] per QALY lost and per extra flare incurred in the Stop group compared to the Continuation group was €368,269 [€155,132, €1,675,909] and €17,670 [€13,650, €22,721], respectively. At willingness-to-accept (WTA) saved amounts of €330,450, €204,496 and €98,438 per QALY lost, the probabilities that withdrawal of TNFis were cost-effective were 0.5, 0.9 and 1.0.


Conclusions: Although an official WTA is not available, the mean saved cost of €368,269 per QALY lost seems to be acceptable in The Netherlands, given existing data on the WTP and the WTA/WTP ratio. If the WTA threshold is €100,000, the probability that stopping TNFis is acceptable is approximately 1.

Out‐of‐pocket Healthcare Spending Burdens among Older Americans with Functional Disabilities
Joelle H. Fong

Older adults with disabilities may face higher out-of-pocket health expenditures than their counterparts even in the presence of public assistance programs. This additional spending that arises due to disability constitutes a financial burden in old age. In this study we assess the effect of functional disability on out-of-pocket health expenses among older adults in the United States. Data is sourced from the Health and Retirement Study (N=7697). Using a two-part multivariate regression model, we estimate the out-of-pocket expenditure (OOPE) for individuals age 70 or older with no disability, mild disability, and severe disability. To gain useful insights into the additional spending among the disabled groups, we also analyze the expenditure breakdown by major health service categories. Our estimates of the average cost burden by disability severity provide direct insights into the scale of healthcare spending differences for individuals across the income spectrum.


In brief, the results show that mild disability is associated with an additional $380 per year in OOPE, whereas severe disability is associated with an additional $490 per year in OOPE, even after controlling for differences across these groups in terms of socio-demographics, chronic conditions, insurance coverage and other characteristics. Nursing home services accounts for bulk of this higher OOPE for disabled individuals. Our cost burden estimates reveal that among elderly persons needing some form of long-term care support, low-income and lower-middle income individuals are the hardest squeezed. The average cost burden for the poorest individuals is 22% while that for individuals between the 25th and 50th percentile of the income distribution is 24%. These findings have important implications for health policies aimed at addressing the economic problems associated with functional disability in a rapidly ageing society.

Can households insure consumption against NCDs in China?
Tianxin Pan; Michael Palmer; Ajay Mahal

There are growing concerns about the rising prevalence of non-communicable diseases (NCDs) worldwide. This phenomenon particularly relates to countries under transition. Currently, there exists little robust evidence on the economic burden of NCDs at the household level and relies predominantly on cross-sectional data. In this paper, we examine whether households in China can insure consumption against NCD onset using longitudinal data and an internationally aligned measure of NCDs. Using three waves of the China Family Panel Studies survey (2010-2014) and a fixed effects specification, we find that households can insure consumption against the onset of a NCD and a significant rise in out-of-pocket health expenditures. However, they are doing so through borrowing, and depleting housing assets to a lesser extent. We find strong heterogeneous effects in the use of coping mechanisms across the population. Urban households sell housing assets whereas rural households draw upon family networks. The poor, who experienced significant decline in income following a NCD shock, had limited means to borrow or sell assets, ended up forgoing medical treatment. The longer-term implication of these coping mechanisms on the well-being of households is precarious and deserves attention from policy makers in the world’s largest transition economy.

Investigating the impact of cognitive impairment on consumer preferences for nursing homes
Rachel Milte; Elisabeth Huynh, Julie Ratcliffe, Maria Crotty

Introduction: Traditionally, people with cognitive impairment and dementia have been excluded from preference elicitation studies in health economics. The aim of this study was to investigate the preferences for psychosocial and environmental characteristics of nursing home care of people with and without cognitive impairment and to assess the impact of cognitive functioning on scale variability in a discrete choice experiment.


Methods: Discrete choice experiment was undertaken with people living in a nursing home without or with mild or moderate cognitive impairment. Data was analysed using conditional logit models for subgroups of participants with and without cognitive impairment separately, and for the entire sample using a heteroscedastic conditional logit regression model allowing for scale heterogeneity. Swait-Louviere test was undertaken to formally test for differences in preference and scale between the two groups.


Results: 126 residents living in a nursing home completed the DCE on their own behalf, 74 (60%) without cognitive impairment while 52 (40%) participated with mild or moderate cognitive impairment. The results of the heteroscedastic conditional logit model indicated cognitive impairment as a statistically significant factor in the model (-0.403 (SE 0.188) p=0.032). The Swait-Louviere test indicated no difference in estimated coefficients between the two subgroups based on presence or absence of cognitive functioning, but evidence of a small but statistically significant difference in scale between the two groups.


While the same preferences are exhibited, there is some evidence of scale variability in people with cognitive impairment living in nursing homes. Hence people with mild cognitive impairment can be considered in preference elicitation studies but it is important to test for and take account of variability in scale. Overall the study demonstrates the potential for DCE as a valuable methodology for determining the preferences of people with mild to moderate cognitive impairment for aged care services

Will public hospital patients choose a better quality hospital given the choice? A discrete choice experiment
Henry Cutler; Yuanyuan Gu; Emma Olin

Publicly funded elective surgery patients in Australia have virtually no choice, instead being directed towards their local public hospital with no regard for quality. Recently, Australian governments have started to explore the potential to offer more choice to improve hospital quality. For success, patients must value quality and exercise their right to choose. Given nearly half of all Australians have private health insurance, and that distances between public hospitals can be vast, Australians may choose “not to choose”.


This study assessed whether Australians want more choice over their public hospital care for elective surgery, and to what extent they value hospital quality relative to greater convenience. A choice modelling experiment was employed, surveying 1,000 Australians aged 50 to 75 years and asking them to choose between two hypothetical hospital choices. Respondents were split into two elective care urgency categories before making their choices to test the impact of surgical urgency on choice.


All choice attributes were significant. Respondents value hospital quality the most, demonstrated through preference for reduced probability of adverse events and readmission rates. Other significant attributes included potential health gain, waiting times, distance from home to the hospital, GP opinion on hospital quality, and other patient experiences.


Respondents were risk averse, willing to trade off an improved health gain for a reduced probability of an adverse event. Other patient experiences were valued similarly to a GP’s opinion on hospital quality. Respondents were willing to wait longer and travel longer distances to receive better quality hospital care. However, respondent characteristics impacted the value of choice attributes.


Results suggest Australians may exercise any increased choice based on differences in hospital quality. Increased public hospital choice could drive quality improvements, particularly if supported by health literacy programs and GP input.

To down‐schedule, or not to down‐schedule, triptans in Australia?
Bonny Parkinson; Mutsa Gumbie; Dr Henry Cutler.

Migraine is a common, chronic, disabling headache disorder. While there is no cure for migraine, there are several treatments available for the prevention of migraines and treatment of acute attacks. Acute treatments aim to reduce the pain severity and migraine duration. They include analgesics, non-steroidal anti-inflammatory drugs (NSAIDs) and triptans. Analgesics and NSAIDs are available over-the-counter (OTC) (Schedule 2 and 3) in Australia, however triptans are available by prescription only (Schedule 4). Down-scheduling triptans will increase the ability of patients to self-medicate before the symptoms have progressed, which will reduce GP consultations, emergency department visits and hospitalisations due to migraines. However, the incidence of adverse events may increase. This study applies an economic evaluation framework to a regulatory decision – whether triptans should be available via prescription only or OTC.


A decision analytic model, with a time horizon of 10 years, was used to synthesise data from a variety of sources. Behaviour before down-scheduling was estimated using a clinician survey data and PBS data, while behaviour after down-scheduling was estimated using a discrete choice experiment. Health outcomes considered included the frequency and duration of migraines, severity, and adverse events, such as fatigue, nausea, myocardial infarction, dyspepsia, serotonin syndrome, and medication over-use headache. Costs relating to GP consultations, medicines, pharmacist time, emergency department visits, hospitalisations, and adverse event costs were included. It was found that down-scheduling triptans results in 930 QALYs gained at a cost of $8.6 million. Consequently the ICER was estimated to be $9,267 per QALY gained. The results were most sensitive to the rate of switching from other OTC medicines to OTC triptans by migraineurs and the rate of medication over-use headache. Overall, down-scheduling triptans is likely to be considered cost-effective by decision makers.

Estimating the impact of paid and unpaid sick leave on preferences for avoiding the negative impacts of foodborne illnesses
Kathleen Manipis; Brendan Mulhern; Philip Haywood; Rosalie Viney; Stephen Goodall

Objective: To estimate societal preferences and the willingness-to-pay (WTP) to avoid the negative impacts of foodborne illnesses.


Methods: Discrete choice methods were used to elicit preferences and estimate the WTP to avoid two acute (gastrointestinal and flu-like illness) and four chronic (irritable bowel syndrome, Guillian-Barre syndrome (GBS), reactive arthritis, and haemolytic uraemic syndrome (HUS)) foodborne illnesses. Respondents across Australia (N=2,043) completed an online survey. The illness duration, and ability to work coupled with sick leave availability were used to describe the impacts of illness for individuals in terms of lost productivity and foregone wages. Costs of treatment were included as an attribute to capture WTP to avoid negative impacts.


Results: Respondents preferred a shorter illness duration, lower treatment costs, having paid sick leave, being able to work, and were more willing to pay the treatment costs associated with a severe than a mild illness. This pattern was consistent across illnesses. Preference results were inconsistent across illness severity, and different levels of ability to work and sick leave availability. When paid sick leave was available, respondents preferred having a severe case of GBS or HUS over having a mild case. WTP to avoid a severe illness was higher than a mild illness. The WTP to avoid a mild acute illness increased when sick leave was unpaid from $5 to $118; and for a mild chronic condition increased from $1,832 to $8,476 when being unable to work increased from some to most of the time, with paid sick leave unavailable.


Discussion: Respondents valued the consequences of foodborne illness based on illness severity, and considered the effect on ability to work to be important. Differences in preferences translate into substantial differences in WTP to avoid an illness. The results will be used in future modelling of the impact of foodborne illnesses on society.

The impact of health insurance on health facilities utilisation
Prastuti Soewondo; Retno Pujisubekti

As membership of Jaminan Kesehatan Nasional (JKN) increases speedily in number (175 million as of April 2017), this paper looks at the role of the private primary care providers in this JKN era. Under JKN, primary care providers become the gatekeepers to hospital care. Private providers have shown high interest to serve JKN patients by signing-up with JKN’s single-payer administrator, BPJS Kesehatan. Our survey finds that, in 2016, the ratio of private to public primary care providers has reached equal proportion, an increase from 30:70 ratio in 2014. However, 70% of JKN members are assigned to public providers (Puskesmas) leading to overcrowding and inadequate or non-existent services to JKN patients, especially, the poorer members of JKN (the PBIs). The number of JKN members registered at one Puskesmas ranged from 12,000 to 190,000 members, whilst private primary care providers only managed on average of 3,000 to 12,000 JKN members. Despite receiving higher capitation rates, most of private primary care providers struggle to maintain surpluses. At the very least, there are three issues in policy design resulting in disincentives to shift JKN patients to the private sector: (1) capitation payments for treating JKN patients are revenues to local governments; (2) local governments are regulated to allocate a minimum of 10% of its revenue to health so naturally they want return to investment; and (3) for sustainability, BPJS prefers to pay lower capitation rates, which applies to Puskesmas.

The impact of Indonesia’s rapid move towards universal health insurance on health expenditure
Meliyanni Johar; Prastuti Soewondo; Ardi Adji; Retno Pujisubekti; Harsa Kunthara Satrio; Iqbal Dawam Wibisono

This study evaluates the impact of JKN on health costs. While JKN might reduce the price of health goods and services by restructuring the provision of public provision of health services, it might also increase health costs if it induces health care utilisation, especially for people with chronic diseases. We use the national socio-economic survey data, SUSENAS, years 2011-2016, involving more than 1.8 million households across all Indonesian provinces. SUSENAS provides data on households’ consumption, whereby the value of transfers or subsidies received for the goods and services consumed are calculated and added to households’ out-of-pocket expenditure. We supplement the SUSENAS data with facility data at the village-level to capture the variations in the economic development stage and health supply in the village where a household resides. We demonstrate the importance of controlling for these variations, as insured households tend to live in economically disadvantage areas with inferior health infrastructure. Focusing on users of health services, we find that, on average, health costs increased over time. JKN has a positive impact at the top of the health cost distribution, suggesting that it largely assists insured households with relatively high medical use, perhaps due to hospitalisation or chronic illnesses. The part of JKN that is specifically targeted for the poor has a larger impact. To further explore heterogeneity in the JKN’s impact, we conduct sub-sample analyses by remoteness of residence and households’ dependency status, specifically households with children under 5 years old, households with elderly members and households with neither an elderly member nor a child under five years.

Access inequality, health insurance and the role of supply factors
Meliyanni Johar; Prastuti Soewondo; Ardi Adji; Retno Pujisubekti; Harsa Kunthara Satrio; Iqbal Dawam Wibisono

Given the improvement in health facilities worldwide, inequity in access to health care is one of the most pertinent issues for health policy and public health. In this study, we quantify how inequalities in health needs, distribution of health infrastructure and the availability of health insurance contribute to the inequality in access to care. Health needs are captured by age-sex profile, reported symptoms and missing days due to illness. The health infrastructures are captured by availability and accessibility to primary, secondary and maternal care facilities. For health insurance, there are public and private/employer-sponsored health insurance memberships. The concentration index (CI) is used as a measure of the degree of the access inequality. The sample is derived from individuals in the national socio-economic data, SUSENAS, years 2011-2016. Socio-economic rank is measured using households’ equivalised total consumption and utilisation is measured at the individual-level. We find that, for both inpatient and outpatient care, CI is positive, but close to zero. For outpatient, access is neither pro-rich nor pro-poor. However, this aggregate CI masks substantive variation across regions. In populous regions such as Sumatra, Java, Bali and Nusa, CI for outpatient use is zero or negative, whilst in east Indonesia (Maluku and Papua), where the population density is much lower, CI is positive. There is also quite a wide variation in inpatient CI, with again east Indonesia facing the largest inequity. The biggest contributor to access inequality is inequality in non-health factors, especially household’s socio-economic condition. Health supply factor and public health insurance, surprisingly, only explain a little, although there are regions where these factors may be effectively used to narrow down the access inequity. The introduction of JKN appears to narrow down the gap in both outpatient and inpatient utilisation.

The Impact of Rural Financial Incentives on Access to Physician Services: Evidence from a Natural Experiment
Megha Swami

Policy makers often use financial incentives to improve recruitment and retention of physicians in rural and remote areas. The General Practice Rural Incentive Program (GPRIP), introduced in 2010, is one such incentive scheme in Australia. There is little empirical evidence on the effect of such incentives on access to physician services in rural areas. This paper evaluates the impact of rural incentives on waiting times for physician services by exploiting an exogenous change in eligibility criteria for rural incentives in 2010 due to GPRIP. Using a unique panel data set of Australian doctors and difference-in-difference methodology, we investigate whether provision of rural incentives reduced waiting times in newly eligible areas and whether this is driven by changes in labour supply of GPs at intensive and/or extensive margin.

Long‐term trends in supply and sustainability of health workforce in remote Aboriginal communities in the Northern Territory
Yuejen Zhao; Deborah J Russell; Steven Guthridge; Mark Ramjan; John Wakerman; Michael P Jones; John S Humphreys

Background: International evidence suggests that a key to improving health for disadvantaged populations are health systems with a strong primary care sector. Longstanding problems with health workforce turnover and supply in remote Aboriginal communities in the Northern Territory (NT) jeopardise the effort to overcome the substantial gaps in health outcomes. This research describes temporal changes in workforce supply in remote NT communities through a period in which there was substantial increase in funds.


Methods: Descriptive and Markov-switching dynamic regression analysis of payroll and financial data for resident health workforce and agency nurses in 54 remote clinics for 2004-2015. The workforce included registered Remote Area Nurses (nurses), Aboriginal Health Practitioners (AHPs) and staff in administrative and logistic roles. Main outcome measures include total number of unique employees per year; average annual headcounts; average full-time equivalent (FTE) positions; agency employed nurse FTE estimates.


Results: Overall increases in workforce supply occurred between 2004 and 2015, especially for administrative and logistic positions. FTE supply of nurses and AHPs increased from an average 2.6 to 3.2 FTE per clinic, although supply of AHPs has declined since 2010. Each year almost twice as many individual NT Government employed nurses or AHPs are required for each FTE position. Two additional aspects of workforce supply, evident for most health clinics, were a fading of supply following initial increase associated with greater funding and a cycle of periods with higher and lower staffing levels.


Conclusions: Overall increases in workforce supply in remote NT communities between 2004 and 2015 have been affected by continuing very high turnover of nurses and AHPs, compounded by recent declines in AHP supply. Despite substantial increases in resourcing an imperative remains to develop more robust health service models which better support the supply and retention of resident health staff.

The Impact of Coercive Policies on Rural Primary Care Inequality and Workforce Outcomes
Laxman Bablani

Empirical evidence on policies aimed at resolving rural workforce shortages is sparse. In our paper, we look at the impact of the Districts of Workforce Shortage program which primarily restricts International Medical Graduates (IMGs) to work in underserved rural and remote areas of Australia. Using a difference-in-differences style design on panel datasets of the Australian doctor workforce, our results indicate that the program is effective at reducing the extent of GP workforce inequality for affected regions. We find this reduction in healthcare inequality is accompanied by a fall in measures of workload viz. patients seen for affected GPs, but not a fall in prices viz. standard consultation fees. We also find no evidence that there is a differential impact of the policy between native and IMG GPs, and therefore cannot accept the hypothesis of imperfect substitutability between native and IMG GPs.

Do Rural Incentives Payments Affect Entries and Exits of General Practitioners?
Hugh Gravelle; Matthew McGrail; Anthony Scott; Peter Sivey; Jongsay Yong

Many countries use financial incentives programs to attract physicians to work in rural areas. This paper tests for the effect of the rural incentives program in Australia by relying on a policy reform in 2010 that introduced a different rurality classification system. As a result of this change, some locations previously ineligible for financial incentives became eligible post-2010. A difference-in-differences approach is employed to analyse how Australian general practitioners (GPs) respond to this change in relation to entry and exit decisions. The main findings are that financial incentives did not have any material impact on attracting or retaining GPs in incentivised locations. However, the incentives were found to attract newly-qualified GPs to locate in the newly-eligible locations. There is little evidence of an effect on other types of locational entries or exits of GPs.

The Effect of School Lunch on Early Teenagers Body Weight
Shiko Maruyama; Sayaka Nakamura

We examine causal effects of Japanese school lunch programs on junior high school students’ weight. In Japan, municipal school lunch provision implies that all municipal school students must eat school lunch, which enables us to assess the population treatment effect and treatment heterogeneity. We use individual level data drawn from the 1975-1994 National Nutrition Survey. To account for possible endogeneity of municipal school lunch provision, we employ difference in differences framework and compare differences between junior high school students and elementary school students between municipalities with and without school lunch at junior high schools. We find no evidence that school lunch affects body weight in the full sample analysis. However, in subsample analysis of children with low socioeconomic background, we find significant negative effect of school lunch on BMI and obesity, in contrast to previous findings of obesity increasing effects of American school lunch programs, probably due to strict nutritional requirements for school lunch in Japan. This weight reducing effect is short-lived and does not accumulate or remain aftermath. These findings are robust to propensity score trimming. Additionally, we do not find support for reverse causality from children’s weight problems to municipal school lunch provision.

Fatter Kids and the Shattered Iron Rice Bowl : Intergenerational Effects of Economic Insecurity During Chinese State‐Owned Enterprise Reform
Weiyang Kong

Studies of the effects of economic insecurity on health usually neglect intergenerational effects. In this paper, I explore the causal effect of parental economic insecurity on children’s weight gain using a policy-induced natural experiment in China. During the late 1990s and the early 2000s, 34 million employees in the state sectors were laid off due to an unanticipated state-owned enterprise reform, which marked the end of the guarantee of employment security. Using the provincial-year level layoff rates and income loss from the layoffs, I estimate its effects on children’s body mass measures adjusting for age and gender growth standards. A continuous difference-in-difference estimation with individual fixed effects indicates that if the expected economic loss from layoff increases by 10 percentage point, a 10-year-old boy increases his body mass measure distribution from the median to the 86th percentile. The results persist even for boys whose parents were not laid-off, indicating the importance of anxiety about potential losses, as well as the experience of actual loss.


Quantile regressions then demonstrate that economic insecurity has greater effects on boys at a higher distribution of waist- to-height ratio, which suggests that overweight children are more severely affected by parental economic insecurity. Girls’ weight outcomes are not significantly affected by the layoffs, suggesting a gender difference in response to parental economic insecurity. As the first paper finding the intergenerational effects of economic insecurity, this paper suggests that the public health costs of economic insecurity could be largely underestimated in the previous literature.