Achievable Cost Saving and Cost-Effective Thresholds for Diabetes Prevention Lifestyle Interventions in People Aged 65 Years and Older: A Single-Payer Perspective

BackgroundMore than 75% of people older than 65 years of age in the United States have prediabetes or diabetes. Diabetes is a burden on Medicare, the US health care payer. Intensive lifestyle interventions have successfully prevented diabetes cases, and medical nutrition therapy has also significantly reduced diabetes risk factors. Including medical nutrition therapy coverage for prediabetes is a policy decision to be made by Medicare, and cost-effectiveness data must support that decision.ObjectiveThe aims of this study were to determine the thresholds of diabetes cases that need to be averted by prediabetes lifestyle interventions in order to be cost saving and/or cost-effective to a single health care insurance payer, such as Medicare; and to compare those thresholds with published intervention data to determine the feasibility of cost savings and/or cost-effectiveness.DesignThis analysis used standard methods of cost-effectiveness and cost saving analysis. A health system perspective was used. Cost estimates for diabetes treatment and lifestyle interventions were based on published data. Costs for 3-, 6-, and 10-year lifestyle interventions were calculated. Sensitivity analyses were performed using least and most-conservative published data for health care and intervention costs.ResultsThe number of cases averted needed for base-case cost savings ranged from 882,883 to 2,443,686, and in sensitivity analysis from 394,148 to 6,738,678. Cost savings are likely in the base and least-conservative scenarios. The number of cases averted needed for base-case cost-effectiveness ranged from 454,755 to 1,258,692, and in sensitivity analysis from 212,225 to 4,843,262. Cost-effectiveness is likely in all interventions, except the 10-year interventions in the most-conservative scenario.ConclusionsPrediabetes lifestyle interventions for people aged 65 years or older are highly cost-effective and possibly cost saving to a health care insurance payer such as Medicare. It is likely that medical nutrition therapy could be even more cost saving and/or cost-effective than intensive lifestyle interventions. These results suggest that Medicare would receive financial benefit from providing coverage for these services.     

Cost-effectiveness of meningococcal polysaccharide serogroups A,C, W-135 and Y conjugate vaccine in Australian adolescents

ObjectivesThe incidence of invasive meningitis disease (IMD) is increasing in Australia. A conjugate vaccine of meningococcal polysaccharide serogroups A, C, W and Y (MenACWY) is currently indicated for infants aged 12 months on the Australian National Immunisation Program. This study sought to determine the cost-effectiveness of a broader MenACWY vaccination program for Australians aged 15 to 19 years.MethodsA Markov model was constructed to simulate the incidence and consequences of IMD in Australians aged 0–84 years, with follow up until age 85 years. The model comprised four health states: ‘Alive with no previous IMD’, ‘Alive, post IMD without long-term complications’, ‘Alive, post IMD with long-term complications’ and ‘Dead’. Decision analysis compared the clinical consequences and costs of a vaccination program versus no vaccination from the perspective of the Australian health care system. Age-specific incidence of IMD and fatality rates were derived from Australian surveillance data. Vaccine coverage, vaccine efficacy and herd immunity were based on published data. The total cost for MenACWY vaccination was AU$56 per dose. Costs and health outcomes were discounted by 5% per annum (in the base-case analysis).ResultsCompared to no vaccination, a MenACWY vaccination program targeted at Australians aged 15–19 years was expected to prevent 1664 IMD cases in the Australian population aged 0–84 years followed up until age 85 years. The program would lead to 1131 life years (LYs) and 2058 quality adjusted life years (QALYs) gained at a total cost of AU$115 million (all discounted values). These equated to incremental cost-effectiveness ratios of AU$101,649 per LY gained and AU$55,857 per QALY gained. A probabilistic sensitivity analysis demonstrated a likelihood of cost-effectiveness of 34.6%, assuming a willingness to pay threshold of AU$50,000 per QALY gained.ConclusionThe likelihood of this program being cost-effective under a willingness to pay threshold AU$50,000 per QALY gained is 35%.     

The case for action on socioeconomic differences in overweight and obesity among Australian adults: modelling the disease burden and healthcare costs

Objective : We aimed to quantify the extent to which socioeconomic differences in body mass index (BMI) drive avoidable deaths, incident disease cases and healthcare costs. Methods : We used population attributable fractions to quantify the annual burden of disease attributable to socioeconomic differences in BMI for Australian adults aged 20 to <85 years in 2016, stratified by quintiles of an area‐level indicator of socioeconomic disadvantage (SocioEconomic Index For Areas Indicator of Relative Socioeconomic Disadvantage; SEIFA) and BMI (normal weight, overweight, obese). We estimated direct healthcare costs using annual estimates per person per BMI category. Results : We attributed $AU1.06 billion in direct healthcare costs to socioeconomic differences in BMI in 2016. The greatest number (proportion) of cases and deaths attributable to socioeconomic differences in BMI was observed for type 2 diabetes among women (8,602 total cases [16%], with 3,471 cases [22%] in the most disadvantaged quintile [SEIFA 1]) and all‐cause mortality among men (2027 total deaths [4%], with 815 deaths [6%] in SEIFA 1). Conclusions : Socioeconomic differences in BMI substantially contribute to avoidable deaths, disease cases and direct healthcare costs in Australia. Implications for public health : Population‐level policies to reduce socioeconomic differences in overweight and obesity must be identified and implemented.     

Using an economic model of diabetes to evaluate prevention and care strategies in Australia

The health benefits and costs of a national diabetes screening and prevention scenario are estimated among Australians ages 45-74. The Australian Diabetes Cost-Benefit Model is used to compare baseline and scenario outcomes from 2000 to 2010. Those newly diagnosed in 2000 receive intensive care, resulting in lower complication rates. People "at high risk" of developing diabetes are offered lifestyle intervention, reducing the numbers developing diabetes. A total of 115,000 people became "newly diagnosed." Among those deemed at high risk, 53,000 avoided developing diabetes by 2010. Average yearly intervention and incremental treatment cost was AU$179 million, with a cost per disability-adjusted life-year of AU$50,000.     

Pneumococcal polysaccharide vaccine is a cost saving strategy for prevention of acute coronary syndrome

ObjectiveThere is evidence that the pneumococcal polysaccharide vaccine (PPV) may reduce cardiovascular disease. We aimed to evaluate the cost-effectiveness of PPV for primary prevention of acute coronary syndrome (ACS) in the elderly in Australia.MethodsA Markov model was developed to investigate the costs, QALYs and ICERs of PPV administration in those aged ≥65 years without a history of ACS from the perspective of Australian healthcare system, using elderly-specific clinical data and local costs from Australian Heart Foundation and Australian Institute of Health and Welfare databases. A ten-years horizon was used, and all costs and health outcomes were discounted at 5% annually. The impact of various assumptions was tested with sensitivity analyses.ResultsIn the base-case analysis, interventional strategy (100% PPV coverage) prevented an additional five incident ACS events among 1000 “healthy” elderly individuals compared with standard of care (50% PPV coverage) over 10 years. 100% PPV was the dominant strategy, resulting in a QALY gain of 0.0075 and cost saving of AU$ 179 per person. The results were most sensitive to effectiveness of PPV at preventing ACS and reducing hospital bed-days, and cost of ACS admission, but in all sensitivity analyses 100% PPV remained the dominant strategy. Shortening the time horizon from ten to five years resulted in further cost saving.ConclusionPPV for the prevention of ACS in those aged ≥65 is a dominant intervention strategy, with cost saving and minor improvements in QALY. Healthcare providers should promote PPV administration for all eligible populations.     

Lower Vegetable Variety and Worsening Diet Quality Over Time Are Associated With Higher 15-Year Health Care Claims and Costs Among Australian Women

BackgroundThe relationship between diet quality and health care costs is unclear.ObjectiveThe aim of this study was to investigate the relationship between baseline diet quality and change in diet quality over time, with 15-year cumulative health care claims/costs.DesignData from a longitudinal cohort study were analyzed.Participants/settingData for survey 3 (2001) (n = 7,868) and survey 7 (2013) (n = 6,349 both time points) from the 1946-1951 cohort of the Australian Longitudinal Study on Women’s Health were analyzed.Main outcome measuresDiet quality was assessed using the Australian Recommended Food Score (ARFS). Fifteen-year cumulative Medicare Benefits Schedule (Australia’s universal health care coverage) data were reported by baseline ARFS quintile and category of diet quality change (“diet quality worsened” [ARFS change ≤ –4 points], “remained stable” [–3 ≤ change in ARFS ≤3 points], or “improved” [ARFS change ≥4 points]).Statistical analysesLinear regression analyses were conducted adjusting for area of residence, socioeconomic status, lifestyle factors, and private health insurance status.ResultsConsuming a greater variety of vegetables at baseline but fewer fruit and dairy products was associated with lower health care costs. For every 1-point increment in the ARFS vegetable subscale, women made 3.3 (95% CI, 1.6-5.0) fewer claims and incurred AU$227 (95% CI, AU$104-350 [US$158; 95% CI, US$72-243]) less in costs. Women whose diet quality worsened over time made more claims (median, 251 claims; quintile 1, quintile 3 [Q1; Q3], 168; 368 claims) and incurred higher costs (AU$15,519; Q1; Q3, AU$9,226; AU$24,847 [US$10,793; Q1; Q3, US$6,417; US$17,281]) compared with those whose diet quality remained stable (median, 236 claims [Q1; Q3, 158; 346 claims], AU$14,515; Q1; Q3, AU$8,539; AU$23,378 [US$10,095; Q1; Q3, US$5,939; US$16,259]).ConclusionsGreater vegetable variety was associated with fewer health care claims and costs; however, this trend was not consistent across other subscales. Worsening diet quality over 12 years was linked with higher health care claims and costs.     

Use of measures of socioeconomic deprivation in planning primary health care workforce and defining health care need in Australia

Objective: To examine whether measures of remoteness areas adequately reveal high need populations, measured against socioeconomic disadvantage and physician to population ratios. Design: Exploratory spatial analysis of relationships between remoteness areas, medical workforce supply and the index of relative socioeconomic disadvantage (IRSD). Bivariate analyses examined associations between remoteness areas and IRSD. From this analysis, a composite score of deprivation was constructed combining measures of remoteness areas, physician to population ratios and IRSD, and validated against health outcome measures. These measures included avoidable mortality per 100 000, risk behaviour rate per 1000, diabetes rate per 1000. All analyses were conducted at the statistical local area level and weighted to be population representative. Results: The percentage of small areas and populations within the most socioeconomically disadvantaged quintile rose with increasing remoteness. However, 12.8% of small areas within major cities and 40.7% of outer regional areas were also within the lowest socioeconomic quintile. There was a strong relationship between our composite score of deprivation and avoidable mortality, risk rate, diabetes rate and per cent Indigenous. Regression analysis examined the relationship between each element of the composite score and health outcomes. This revealed that the association between avoidable mortality and remoteness was lost after controlling for per cent Indigenous. Conclusions: Using remoteness areas alone to prioritise workforce incentive programs and training requirements has significant limitations. Including measures of socioeconomic disadvantage and workforce supply would better target health inequities and improve resource allocation in Australia.     

Cost-Effectiveness of Statins for Primary Prevention in Patients Newly Diagnosed with Type 2 Diabetes in The Netherlands

BackgroundStatins are lipid-lowering drugs that reduce the risk of cardiovascular events in patients with diabetes.ObjectivesThe objective of this study was to determine whether statin treatment for primary prevention in newly diagnosed type 2 diabetes is cost-effective, taking nonadherence, baseline risk, and age into account.MethodsA cost-effectiveness analysis was performed by using a Markov model with a time horizon of 10 years. The baseline 10-year cardiovascular risk was estimated in a Dutch population of primary prevention patients with newly diagnosed diabetes from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database, using the United Kingdom Prospective Diabetes Study risk engine. Statin adherence was measured as pill days covered in the IADB.nl pharmacy research database. Cost-effectiveness was measured in costs per quality-adjusted life-year (QALY) from the health care payers’ perspective.ResultsFor an average patient aged 60 years, the base case, statin treatment was highly cost-effective at €2245 per QALY. Favorable cost-effectiveness was robust in sensitivity analysis. Differences in age and 10-year cardiovascular risk showed large differences in cost-effectiveness from almost €100,000 per QALY to almost being cost saving. Treating all patients younger than 45 years at diabetes diagnosis was not cost-effective (weighted cost-effectiveness of almost €60,000 per QALY).ConclusionsDespite the nonadherence levels observed in actual practice, statin treatment is cost-effective for primary prevention in patients newly diagnosed with type 2 diabetes. Because of large differences in cost-effectiveness according to different risk and age groups, the efficiency of the treatment could be increased by targeting patients with relatively higher cardiovascular risk and higher ages.     

Diabetes prevalence and socioeconomic status: a population based study showing increased prevalence of type 2 diabetes mellitus in deprived areas

OBJECTIVE: To establish the relation between socioeconomic status and the age-sex specific prevalence of type 1 and type 2 diabetes mellitus. The hypothesis was that prevalence of type 2 diabetes would be inversely related to socioeconomic status but there would be no association with the prevalence of type 1 diabetes and socioeconomic status. SETTING: Middlesbrough and East Cleveland, United Kingdom, district population 287,157. PATIENTS: 4313 persons with diabetes identified from primary care and hospital records. RESULTS: The overall age adjusted prevalence was 15.60 per 1000 population. There was a significant trend between the prevalence of type 2 diabetes and quintile of deprivation score in men and women (chi 2 for linear trend, p < 0.001). In men the prevalence in the least deprived quintile was 13.4 per 1000 (95% confidence intervals (95% CI) 11.44, 15.36) compared with 17.22 per 1000 (95% CI 15.51, 18.92) in the most deprived. For women the prevalence was 10.84 per 1000 (95% CI 9.00, 12.69) compared with 15.48 per 1000 (95% CI 13.84, 17.11) in the most deprived. The increased prevalence of diabetes in the most deprived areas was accounted for by increased prevalence of type 2 diabetes in the age band 40-69 years. There was no association between the prevalence of type 1 diabetes and socioeconomic status. CONCLUSION: These data confirm an inverse association between socioeconomic status and the prevalence of type 2 diabetes in the middle years of life. This finding suggests that exposure to factors that are implicated in the causation of diabetes is more common in deprived areas.     

Socioeconomic status and tobacco expenditure among Australian households: results from the 1998-99 Household Expenditure Survey

OBJECTIVE: To investigate the relation between socioeconomic status (SES) and tobacco expenditure among Australian households. DESIGN AND SETTING: Cross sectional study (The Household Expenditure Survey 1998-99) by the Australian Bureau of Statistics, based on a multi-stage national sample of 9682 households. PARTICIPANTS: From selected households, all members aged 15 and over were interviewed. MAIN RESULTS: Lower SES was associated with higher odds of reporting tobacco expenditure. Among smoking households, those from lower SES spent more of their funds on tobacco. For example, households headed by a person with no educational qualification spent 34% more on tobacco than those headed by a person with a university degree. Blue collar households spent 23% more than professional households. Percentage of total household expenditure on tobacco in the first income quintile was 62% more than that of households in the fifth quintile. CONCLUSION: Antismoking interventions and policies that are specifically aimed at lower SES groups can potentially improve social equality. They can also ameliorate social inequalities in health, given that much of the SES differentials in morbidity and mortality are attributed to the pronounced SES gradient in smoking.     

Unhealthy Diet Pattern Mediates the Disproportionate Prevalence of Obesity among Adults with Socio-Economic Disadvantage: An Australian Representative Cross-Sectional Study

The role of unhealthy dietary pattern in the association between socio-economic factors and obesity is unclear. The aim was to examine the association between socio-economic disadvantage and obesity and to assess mediation effect of unhealthy dietary pattern defined using the Mediterranean diet criteria. The data source was the Australian National Nutrition and Physical Activity Survey. The study sample included 7744 participants aged 18 years and over, 28% of whom had obesity. We used the Australian Socio-Economic Indexes for Areas (SEIFA) classification system for categorizing socio-economic disadvantage; calculated the Mediterranean Diet Score (MDS) using standard criteria; and used measured body mass index to define obesity. We conducted a mediation analysis using log–binomial models to generate the prevalence ratio for obesity and the proportion mediated by the MDS. The most disadvantaged group was associated with higher level of obesity after controlling for covariates (1.40, 95% CI 1.25, 1.56) compared to the least disadvantaged group, and in a dose–response way for each decreasing SEIFA quintile. The relationship between socio-economic disadvantage and obesity was mediated by the MDS (4.0%, 95% CI 1.9, 8.0). Public health interventions should promote healthy dietary patterns, such as the Mediterranean diet, to reduce obesity, especially in communities with high socio-economic disadvantage.     

Cost-Effectiveness of the New 2018 American College of Physicians Glycemic Control Guidance Statements Among US Adults With Type 2 Diabetes

ObjectivesThis study aims to estimate the national impact and cost-effectiveness of the 2018 American College of Physicians (ACP) guidance statements compared to the status quo.MethodsSurvey data from the 2011-2016 National Health and Nutrition Examination were used to generate a national representative sample of individuals with diagnosed type 2 diabetes in the United States. Individuals with A1c <6.5% on antidiabetic medications are recommended to deintensify their A1c level to 7.0% to 8.0% (group 1); individuals with A1c 6.5% to 8.0% and a life expectancy of <10 years are recommended to deintensify their A1c level >8.0% (group 2); and individuals with A1c >8.0% and a life expectancy of >10 years are recommended to intensify their A1c level to 7.0% to 8.0% (group 3). We used a Markov-based simulation model to evaluate the lifetime cost-effectiveness of following the ACP recommended A1c level.Results14.41 million (58.1%) persons with diagnosed type 2 diabetes would be affected by the new guidance statements. Treatment deintensification would lead to a saving of $363 600 per quality-adjusted life-year (QALY) lost for group 1 and a saving of $118 300 per QALY lost for group 2. Intensifying treatment for group 3 would lead to an additional cost of $44 600 per QALY gain. Nationally, the implementation of the guidance would add 3.2 million life-years and 1.1 million QALYs and reduce healthcare costs by $47.7 billion compared to the status quo.ConclusionsImplementing the new ACP guidance statements would affect a large number of persons with type 2 diabetes nationally. The new guidance is cost-effective.     

The cost of a healthy and sustainable diet – who can afford it?

Objective: Climate change is affecting the ability of food systems to provide sufficient nutritious and affordable foods at all times. Healthy and sustainable (H&S) food choices are important contributions to health and climate change policy efforts. This paper presents empirical data on the affordability of a food basket that incorporates principles of health and sustainability across different food sub‐systems, socioeconomic neighbourhoods and household income levels in Greater Western Sydney, Australia. Methods: A basket survey was used to investigate the cost of both a typical basket of food and a hypothetical H&S basket. The price of foods in the two baskets was recorded in five neighbourhoods, and the affordability of the baskets was determined across household income quintiles. Results: The cost of the H&S basket was more than the typical basket in all five socioeconomic neighbourhoods, with most disadvantaged neighbourhood spending proportionately more (30%) to buy the H&S basket. Within household income levels, the greatest inequity was found in the middle income neighbourhood, showing that households in the lowest income quintile would have to spend up to 48% of their weekly income to buy the H&S basket, while households in the highest income quintile would have to spend significantly less of their weekly income (9%). Conclusion: The most disadvantaged groups in the region, both at the neighbourhood and household level, experience the greatest inequality in affordability of the H&S diet. Implications: The results highlight the current inequity in food choice in the region and the underlying social issues of cost and affordability of H&S foods.     

The cost-effectiveness of installing sidewalks to increase levels of transport-walking and health

ObjectiveThis study investigated the cost-effectiveness of installing sidewalks to increase levels of transport-walking.MethodsSecondary analysis using logistic regression established the association of sidewalks with transport-walking using two transport-walking thresholds of 150 and 60 min/week using Western Australian data (n = 1394) from 1995 to 2000. Minimum, moderate and maximum interventions were defined, associated respectively with one sidewalk, at least one sidewalk and sidewalks on both sides of the street. Costs, average and incremental cost-effectiveness ratios were calculated for each intervention and expressed as ‘the cost per person who walks for transport for more than 150 min/week (60 min/week) after the installation of new sidewalks’. A sensitivity analysis examined the robustness of the incremental cost-effectiveness ratios to varying model inputs. Costs are in 2012 Australian dollars.ResultsA positive relationship was found between the presence of sidewalks and transport-walking for both transport-walking thresholds of 150 and 60 min/week. The minimum intervention was found to be the most cost-effective at $2330/person and $674/person for the 150 and 60 min/week transport-walking thresholds respectively. Increasing the proportion of people transport-walking and increasing population density by 50% improved the cost-effectiveness of installing side-walks to $346/person.ConclusionsTo increase levels of transport-walking, retrofitting streets with one sidewalk is most cost-effective.     

Social disadvantage and variation in the incidence of end-stage renal disease in Australian capital cities

OBJECTIVE: To evaluate variation in the incidence of end-stage renal disease (ESRD) within Australian capital cities. To explore the relation between the incidence of ESRD and socioeconomic disadvantage. METHODS: We obtained data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) regarding 5,013 patients from capital cities who started ESRD treatment between 1 April 1993 and 31 December 1998. We used the postcode at the start of treatment to calculate the average annual incidence of ESRD for each of 51 capital city regions using 1996 Census counts based on place of usual residence. We calculated standardised incidence ratios with 95% confidence intervals for each region. The standardised incidence ratios were examined in relation to the SEIFA Index of Relative Socio-economic Disadvantage (IRSD), derived from the 1996 Census. Low IRSD values indicate more disadvantaged areas. RESULTS: There is significant variation in the standardised incidence of ESRD within capital cities. There was a significant correlation (r=-0.41, p=0.003) between the standardised incidence ratio for ESRD and the SEIFA IRSD. CONCLUSIONS AND IMPLICATIONS: Capital city areas that are more disadvantaged have a higher incidence of ESRD. Socioeconomic factors may be important determinants of the risk of developing ESRD.     

Socioeconomic Predictors of Diabetes Mortality in Japan: An Ecological Study Using Municipality-specific Data

ObjectivesThe aim of this study was to examine the geographic distribution of diabetes mortality in Japan and identify socioeconomic factors affecting differences in municipality-specific diabetes mortality.MethodsDiabetes mortality data by year and municipality from 2013 to 2017 were extracted from Japanese Vital Statistics, and the socioeconomic characteristics of municipalities were obtained from government statistics. We calculated the standardized mortality ratio (SMR) of diabetes for each municipality using the empirical Bayes method and represented geographic differences in SMRs in a map of Japan. Multiple linear regression was conducted to identify the socioeconomic factors affecting differences in SMR. Statistically significant socioeconomic factors were further assessed by calculating the relative risk of mortality of quintiles of municipalities classified according to the degree of each socioeconomic factor using Poisson regression analysis.ResultsThe geographic distribution of diabetes mortality differed by gender. Of the municipality-specific socioeconomic factors, high rates of single-person households and unemployment and a high number of hospital beds were associated with a high SMR for men. High rates of fatherless households and blue-collar workers were associated with a high SMR for women, while high taxable income per-capita income and total population were associated with low SMR for women. Quintile analysis revealed a complex relationship between taxable income and mortality for women. The mortality risk of quintiles with the highest and lowest taxable per-capita income was significantly lower than that of the middle-income quintile.ConclusionsSocioeconomic factors of municipalities in Japan were found to affect geographic differences in diabetes mortality.     

Improving the cost-effectiveness of cardiovascular disease prevention in Australia: a modelling study

ABSTRACT: BACKGROUND: Cardiovascular disease is the leading cause of death worldwide. Like many countries, Australia is currently changing its guidelines for cardiovascular disease prevention from drug treatment for everyone with 'high blood pressure' or 'high cholesterol', to prevention based on a patient's absolute risk. In this research, we model cost-effectiveness of cardiovascular disease prevention with blood pressure and lipid drugs in Australia under three different scenarios: (1) the true current practice in Australia; (2) prevention as intended under the current guidelines; and (3) prevention according to proposed absolute risk levels. We consider the implications of changing to absolute risk-based cardiovascular disease prevention, for the health of the Australian people and for Government health sector expenditure over the long term. METHODS: We evaluate cost-effectiveness of statins, diuretics, ACE inhibitors, calcium channel blockers and beta-blockers, for Australian men and women, aged 35 to 84 years, who have never experienced a heart disease or stroke event. Epidemiological changes and health care costs are simulated by age and sex in a discrete time Markov model, to determine total impacts on population health and health sector costs over the lifetime, from which we derive cost-effectiveness ratios in 2008 Australian dollars per quality-adjusted life year. RESULTS: Cardiovascular disease prevention based on absolute risk is more cost-effective than prevention under the current guidelines based on single risk factor thresholds, and is more cost-effective than the current practice, which does not follow current clinical guidelines. Recommending blood pressure-lowering drugs to everyone with at least 5% absolute risk and statin drugs to everyone with at least 10% absolute risk, can achieve current levels of population health, while saving $5.4 billion for the Australian Government over the lifetime of the population. But savings could be as high as $7.1 billion if Australia could match the cheaper price of statin drugs in New Zealand. CONCLUSIONS: Changing to absolute risk-based cardiovascular disease prevention is highly recommended for reducing health sector spending, but the Australian Government must also consider measures to reduce the cost of statin drugs, over and above the legislated price cuts of November 2010.     

Neighbourhood disadvantage and smoking: Examining the role of neighbourhood-level psychosocial characteristics

PurposeThis study aims to determine if neighbourhood psychosocial characteristics contribute to inequalities in smoking among residents from neighbourhoods of differing socioeconomic disadvantage.MethodsThis cross-sectional study includes 11,035 residents from 200 neighbourhoods in Brisbane, Australia in 2007. Self-reported measures were obtained for smoking and neighbourhood psychosocial characteristics (perceptions of incivilities, crime and safety, and social cohesion). Neighbourhood socioeconomic disadvantage was measured using a census-derived index. Data were analysed using multilevel logistic regression random intercept models.ResultsSmoking was associated with neighbourhood disadvantage; this relationship remained after adjustment for individual-level socioeconomic position. Area-level perceptions of crime and safety and social cohesion were not independently associated with smoking, and did not explain the higher prevalence of smoking in disadvantaged areas; however, perceptions of incivilities showed an independent effect.ConclusionsSome neighbourhood psychosocial characteristics seem to contribute to the higher rates of smoking in disadvantaged areas.     

Adolescent,parent and societal preferences and willingness to pay for meningococcal B vaccine: A Discrete Choice Experiment

ObjectiveMeningococcal B (MenB) vaccines have been licensed in many countries with private purchase the only option until recently, when a funded programme was introduced in the UK. The aim of this study was to explore adolescent/parental values for a variety of salient vaccine attributes (cost, effectiveness, side effect profile) to assess preferences and willingness-to-pay (WTP) for a MenB vaccine.MethodologyA national cross-sectional population study was conducted in Australia using Discrete Choice Experiment methodology to assess adolescent/parent/adult preferences for attributes related to MenB vaccine.Results2003 adults and 502 adolescents completed the survey in 2013. The majority of participants were willing to be vaccinated with MenB vaccine with vaccination opt-out chosen by 11.9% of adolescents and parents, and 18.2% of non-parent adults. A mixed logit regression model examining adolescent/adult preferences indicated consistent findings; the higher the effectiveness, the longer the duration of protection, the less chance of adverse events and the lower the cost, the more likely respondents were to agree to vaccination. For an ideal MenB vaccine, including the most favoured level of each attribute summed together (90% effectiveness, 10 year duration, 1 injection, no adverse events) adolescents would pay AU$251.60 and parents AU$295.10. Adolescents and parents would pay AU$90.70 or AU$127.20 for 90% vaccine effectiveness vs AU$18.50 or AU$16.70 for 70% effectiveness and would want to be financially compensated for 50% effectiveness; pay AU$63.30 or AU$76.40 for 10 years protection; and pay AU$48.50 or AU$49.20 for no vaccine related adverse events. A slight fever post vaccination was a preferred choice with parents and adolescents willing to pay AU$9.60 or AU$12.30 for this attribute.ConclusionsVaccine effectiveness, adverse events and duration of immunity are important drivers for parental and adolescent decisions about WTP for MenB vaccine and should be included in discussions on the benefits, risks and cost.     

Neighbourhood socioeconomic inequalities in incidence of acute myocardial infarction: a cohort study quantifying age- and gender-specific differences in relative and absolute terms

ABSTRACT: BACKGROUND: Socioeconomic status has a profound effect on the risk of having a first acute myocardial infarction (AMI). Information on socioeconomic inequalities in AMI incidence across age- gender-groups is lacking. Our objective was to examine socioeconomic inequalities in the incidence of AMI considering both relative and absolute measures of risk differences, with a particular focus on age and gender. METHODS: We identified all patients with a first AMI from 1997 to 2007 through linked hospital discharge and death records covering the Dutch population. Relative risks (RR) of AMI incidence were estimated by mean equivalent household income at neighbourhood-level for strata of age and gender using Poisson regression models. Socioeconomic inequalities were also shown within the stratified age-gender groups by calculating the total number of events attributable to socioeconomic disadvantage. RESULTS: Between 1997 and 2007, 317,564 people had a first AMI. When comparing the most deprived socioeconomic quintile with the most affluent quintile, the overall RR for AMI was 1.34 (95% confidence interval (CI): 1.32 - 1.36) in men and 1.44 (95% CI: 1.42 - 1.47) in women. The socioeconomic gradient decreased with age. Relative socioeconomic inequalities were most apparent in men under 35 years and in women under 65 years. The largest number of events attributable to socioeconomic inequalities was found in men aged 45-74 years and in women aged 65-84 years. The total proportion of AMIs that was attributable to socioeconomic inequalities in the Dutch population of 1997 to 2007 was 14% in men and 18% in women. CONCLUSIONS: Neighbourhood socioeconomic inequalities were observed in AMI incidence in the Netherlands, but the magnitude across age-gender groups depended on whether inequality was expressed in relative or absolute terms. Relative socioeconomic inequalities were high in young persons and women, where the absolute burden of AMI was low. Absolute socioeconomic inequalities in AMI were highest in the age-gender groups of middle-aged men and elderly women, where the number of cases was largest.