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1.  The impact of funding deadlines on personal workloads, stress and family relationships: a qualitative study of Australian researchers 
BMJ Open  2014;4(3):e004462.
Objective
To examine the impact of applying for funding on personal workloads, stress and family relationships.
Design
Qualitative study of researchers preparing grant proposals.
Setting
Web-based survey on applying for the annual National Health and Medical Research Council (NHMRC) Project Grant scheme.
Participants
Australian researchers (n=215).
Results
Almost all agreed that preparing their proposals always took top priority over other work (97%) and personal (87%) commitments. Almost all researchers agreed that they became stressed by the workload (93%) and restricted their holidays during the grant writing season (88%). Most researchers agreed that they submitted proposals because chance is involved in being successful (75%), due to performance requirements at their institution (60%) and pressure from their colleagues to submit proposals (53%). Almost all researchers supported changes to the current processes to submit proposals (95%) and peer review (90%). Most researchers (59%) provided extensive comments on the impact of writing proposals on their work life and home life. Six major work life themes were: (1) top priority; (2) career development; (3) stress at work; (4) benefits at work; (5) time spent at work and (6) pressure from colleagues. Six major home life themes were: (1) restricting family holidays; (2) time spent on work at home; (3) impact on children; (4) stress at home; (5) impact on family and friends and (6) impact on partner. Additional impacts on the mental health and well-being of researchers were identified.
Conclusions
The process of preparing grant proposals for a single annual deadline is stressful, time consuming and conflicts with family responsibilities. The timing of the funding cycle could be shifted to minimise applicant burden, give Australian researchers more time to work on actual research and to be with their families.
doi:10.1136/bmjopen-2013-004462
PMCID: PMC3975760  PMID: 24682577
Public Health; Qualitative Research; Mental Health; Medical Education & Training
2.  Control strategies to prevent total hip replacement-related infections: a systematic review and mixed treatment comparison 
BMJ Open  2014;4(3):e003978.
Objective
To synthesise the available evidence and estimate the comparative efficacy of control strategies to prevent total hip replacement (THR)-related surgical site infections (SSIs) using a mixed treatment comparison.
Design
Systematic review and mixed treatment comparison.
Setting
Hospital and other healthcare settings.
Participants
Patients undergoing THR.
Primary and secondary outcome measures
The number of THR-related SSIs occurring following the surgical operation.
Results
12 studies involving 123 788 THRs and 9 infection control strategies were identified. The strategy of ‘systemic antibiotics+antibiotic-impregnated cement+conventional ventilation’ significantly reduced the risk of THR-related SSI compared with the referent strategy (no systemic antibiotics+plain cement+conventional ventilation), OR 0.13 (95% credible interval (CrI) 0.03–0.35), and had the highest probability (47–64%) and highest median rank of being the most effective strategy. There was some evidence to suggest that ‘systemic antibiotics+antibiotic-impregnated cement+laminar airflow’ could potentially increase infection risk compared with ‘systemic antibiotics+antibiotic-impregnated cement+conventional ventilation’, 1.96 (95% CrI 0.52–5.37). There was no high-quality evidence that antibiotic-impregnated cement without systemic antibiotic prophylaxis was effective in reducing infection compared with plain cement with systemic antibiotics, 1.28 (95% CrI 0.38–3.38).
Conclusions
We found no convincing evidence in favour of the use of laminar airflow over conventional ventilation for prevention of THR-related SSIs, yet laminar airflow is costly and widely used. Antibiotic-impregnated cement without systemic antibiotics may not be effective in reducing THR-related SSIs. The combination with the highest confidence for reducing SSIs was ‘systemic antibiotics+antibiotic-impregnated cement+conventional ventilation’. Our evidence synthesis underscores the need to review current guidelines based on the available evidence, and to conduct further high-quality double-blind randomised controlled trials to better inform the current clinical guidelines and practice for prevention of THR-related SSIs.
doi:10.1136/bmjopen-2013-003978
PMCID: PMC3948634  PMID: 24604480
EPIDEMIOLOGY
3.  The increased risks of death and extra lengths of hospital and ICU stay from hospital-acquired bloodstream infections: a case–control study 
BMJ Open  2013;3(10):e003587.
Objectives
Hospital-acquired bloodstream infections are known to increase the risk of death and prolong hospital stay, but precise estimates of these two important outcomes from well-designed studies are rare, particularly for non-intensive care unit (ICU) patients. We aimed to calculate accurate estimates, which are vital for estimating the economic costs of hospital-acquired bloodstream infections.
Design
Case–control study.
Setting
9 Australian public hospitals.
Participants
All the patients were admitted between 2005 and 2010.
Primary and secondary outcome measures
Risk of death and extra length of hospital stay associated with nosocomial infection.
Results
The greatest increase in the risk of death was for a bloodstream infection with methicillin-resistant Staphylococcus aureus (HR=4.6, 95% CI 2.7 to 7.6). This infection also had the longest extra length of stay to discharge in a standard bed (12.8 days, 95% CI 6.2 to 26.1 days). All the eight bloodstream infections increased the length of stay in the ICU, with longer stays for the patients who eventually died (mean increase 0.7–6.0 days) compared with those who were discharged (mean increase: 0.4–3.1 days). The three most common organisms associated with Gram-negative infection were Escherichia coli, Pseudomonas aeruginosa and Klebsiella pneumonia.
Conclusions
Bloodstream infections are associated with an increased risk of death and longer hospital stay. Avoiding infections could save lives and free up valuable bed days.
doi:10.1136/bmjopen-2013-003587
PMCID: PMC3816236  PMID: 24176795
Infectious Diseases; General Medicine (see Internal Medicine); Intensive & Critical Care
4.  Moving MobileMums forward: protocol for a larger randomized controlled trial of an improved physical activity program for women with young children 
BMC Public Health  2013;13:593.
Background
Women with young children (under 5 years) are a key population group for physical activity intervention. Previous evidence highlights the need for individually tailored programs with flexible delivery mechanisms for this group. Our previous pilot study suggested that an intervention primarily delivered via mobile phone text messaging (MobileMums) increased self-reported physical activity in women with young children. An improved version of the MobileMums program is being compared with a minimal contact control group in a large randomised controlled trial (RCT).
Methods/design
This RCT will evaluate the efficacy, feasibility and acceptability, cost-effectiveness, mediators and moderators of the MobileMums program. Primary (moderate-vigorous physical activity) and secondary (intervention implementation data, health service use costs, intervention costs, health benefits, theoretical constructs) outcomes are assessed at baseline, 3-months (end of intervention) and 9-months (following 6-month no contact: maintenance period).
The intervention commences with a face-to-face session with a behavioural counsellor to initiate rapport and gather information for tailoring the 12-week text message program. During the program participants also have access to a: MobileMums Participant Handbook, MobileMums refrigerator magnet, MobileMums Facebook© group, and a MobileMums website with a searchable, on-line exercise directory. A nominated support person also receives text messages for 12-weeks encouraging them to offer their MobileMum social support for physical activity.
Discussion
Results of this trial will determine the efficacy and cost-effectiveness of the MobileMums program, and the feasibility of delivering it in a community setting. It will inform the broader literature of physical activity interventions for women with young children and determine whether further investment in the translation of the program is warranted.
Trial registration
The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611000481976).
doi:10.1186/1471-2458-13-593
PMCID: PMC3733692  PMID: 23777245
Text message; SMS; Mobile telephone; Postnatal women; Exercise; Intervention
5.  On the time spent preparing grant proposals: an observational study of Australian researchers 
BMJ Open  2013;3(5):e002800.
Objective
To estimate the time spent by the researchers for preparing grant proposals, and to examine whether spending more time increase the chances of success.
Design
Observational study.
Setting
The National Health and Medical Research Council (NHMRC) of Australia.
Participants
Researchers who submitted one or more NHMRC Project Grant proposals in March 2012.
Main outcome measures
Total researcher time spent preparing proposals; funding success as predicted by the time spent.
Results
The NHMRC received 3727 proposals of which 3570 were reviewed and 731 (21%) were funded. Among our 285 participants who submitted 632 proposals, 21% were successful. Preparing a new proposal took an average of 38 working days of researcher time and a resubmitted proposal took 28 working days, an overall average of 34 days per proposal. An estimated 550 working years of researchers' time (95% CI 513 to 589) was spent preparing the 3727 proposals, which translates into annual salary costs of AU$66 million. More time spent preparing a proposal did not increase the chances of success for the lead researcher (prevalence ratio (PR) of success for 10 day increase=0.91, 95% credible interval 0.78 to 1.04) or other researchers (PR=0.89, 95% CI 0.67 to 1.17).
Conclusions
Considerable time is spent preparing NHMRC Project Grant proposals. As success rates are historically 20–25%, much of this time has no immediate benefit to either the researcher or society, and there are large opportunity costs in lost research output. The application process could be shortened so that only information relevant for peer review, not administration, is collected. This would have little impact on the quality of peer review and the time saved could be reinvested into research.
doi:10.1136/bmjopen-2013-002800
PMCID: PMC3664356  PMID: 23793700
Research funding; Evidence based medicine; Peer review; Statistics & research methods
6.  Surgical treatment approaches and reimbursement costs of surgical site infections post hip arthroplasty in Australia: a retrospective analysis 
Background
The treatment for deep surgical site infection (SSI) following primary total hip arthroplasty (THA) varies internationally and it is at present unclear which treatment approaches are used in Australia. The aim of this study is to identify current treatment approaches in Queensland, Australia, show success rates and quantify the costs of different treatments.
Methods
Data for patients undergoing primary THA and treatment for infection between January 2006 and December 2009 in Queensland hospitals were extracted from routinely used hospital databases. Records were linked with pathology information to confirm positive organisms. Diagnosis and treatment of infection was determined using ICD-10-AM and ACHI codes, respectively. Treatment costs were estimated based on AR-DRG cost accounting codes assigned to each patient hospital episode.
Results
A total of n=114 patients with deep surgical site infection were identified. The majority of patients (74%) were first treated with debridement, antibiotics and implant retention (DAIR), which was successful in eradicating the infection in 60.3% of patients with an average cost of $13,187. The remaining first treatments were 1-stage revision, successful in 89.7% with average costs of $27,006, and 2-stage revisions, successful in 92.9% of cases with average costs of $42,772. Multiple treatments following ‘failed DAIR’ cost on average $29,560, for failed 1-stage revision were $24,357, for failed 2-stage revision were $70,381 and were $23,805 for excision arthroplasty.
Conclusions
As treatment costs in Australia are high primary prevention is important and the economics of competing treatment choices should be carefully considered. These currently vary greatly across international settings.
doi:10.1186/1472-6963-13-91
PMCID: PMC3601983  PMID: 23497364
Hip replacement arthroplasty; Surgical wound infection; Cost analysis; Outcome assessment; Surgical revision
7.  Development of an economic model to assess the cost-effectiveness of hawthorn extract as an adjunct treatment for heart failure in Australia 
BMJ Open  2012;2(5):e001094.
Objective
An economic model was developed to evaluate the cost-effectiveness of hawthorn extract as an adjunctive treatment for heart failure in Australia.
Methods
A Markov model of chronic heart failure was developed to compare the costs and outcomes of standard treatment and standard treatment with hawthorn extract. Health states were defined by the New York Heart Association (NYHA) classification system and death. For any given cycle, patients could remain in the same NYHA class, experience an improvement or deterioration in NYHA class, be hospitalised or die. Model inputs were derived from the published medical literature, and the output was quality-adjusted life years (QALYs). Probabilistic sensitivity analysis was conducted. The expected value of perfect information (EVPI) and the expected value of partial perfect information (EVPPI) were conducted to establish the value of further research and the ideal target for such research.
Results
Hawthorn extract increased costs by $1866.78 and resulted in a gain of 0.02 QALYs. The incremental cost-effectiveness ratio was $85 160.33 per QALY. The cost-effectiveness acceptability curve indicated that at a threshold of $40 000 the new treatment had a 0.29 probability of being cost-effective. The average incremental net monetary benefit (NMB) was −$1791.64, the average NMB for the standard treatment was $92 067.49, and for hawthorn extract $90 275.84. Additional research is potentially cost-effective if research is not proposed to cost more than $325 million. Utilities form the most important target parameter group for further research.
Conclusions
Hawthorn extract is not currently considered to be cost-effective in as an adjunctive treatment for heart failure in Australia. Further research in the area of utilities is warranted.
doi:10.1136/bmjopen-2012-001094
PMCID: PMC3437431  PMID: 22942231
Health economics; Cardiology; Heart failure; Complementary Medicine
8.  Productivity and Time Use during Occupational Therapy and Nutrition/Dietetics Clinical Education: A Cohort Study 
PLoS ONE  2012;7(8):e44356.
Background
Currently in the Australian higher education sector higher productivity from allied health clinical education placements is a contested issue. This paper will report results of a study that investigated output changes associated with occupational therapy and nutrition/dietetics clinical education placements in Queensland, Australia. Supervisors’ and students’ time use during placements and how this changes for supervisors compared to when students are not present in the workplace is also presented.
Methodology/Principal Findings
A cohort design was used with students from four Queensland universities, and their supervisors employed by Queensland Health. There was an increasing trend in the number of occasions of service delivered when the students were present, and a statistically significant increase in the daily mean length of occasions of service delivered during the placement compared to pre-placement levels.
Conclusions/Significance
A novel method for estimating productivity and time use changes during clinical education programs for allied health disciplines has been applied. During clinical education placements there was a net increase in outputs, suggesting supervisors engage in longer consultations with patients for the purpose of training students, while maintaining patient numbers. Other activities were reduced. This paper is the first time these data have been shown in Australia and form a sound basis for future assessments of the economic impact of student placements for allied health disciplines.
doi:10.1371/journal.pone.0044356
PMCID: PMC3432118  PMID: 22952964
9.  Open versus closed IV infusion systems: a state based model to predict risk of catheter associated blood stream infections 
BMJ Open  2011;1(2):e000188.
Objectives
To quantify the change in risk of central line associated blood stream infection (CLABSI) following the introduction of a closed infusion container in intensive care units (ICUs) in two Latin American cities.
Design
A state-space model was used to describe the flow of admissions through the ICU. This approach correctly treats infection as a time-dependent covariate.
Results
A closed system reduced the risk of CLABSI. The hazard ratios for the closed versus open container were between 0.15 and 0.31 (p values<0.001), indicating a clinically significant reduction in the risk of admissions having a CLABSI. A simulation study showed that a closed system reduced the number of infections, costs and deaths.
Conclusions
The data reveal costs are saved and health benefits gained from fewer cases of CLABSI after adoption of a closed infusion system. Information is required on the costs of implementing the closed system widely in these settings.
Article summary
Article focus
The risks of central line associated blood stream infections among patients in intensive care units (ICUs) in Mexico and São Paulo were examined.
Risks before and after the introduction of closed infusion containers were compared.
Simulation studies revealed the impact of the change on the amount of bed days and number of deaths.
Key messages
Risks were reduced in both cities after the introduction of closed infusion containers and there was a statistically significant reduction in the number of deaths in both cities.
A large reduction in bed days was observed in São Paulo but not in Mexico.
Closed instead of open infusion systems among ICU patients reduces the risks of central line associated blood stream infections, decreases costs and saves lives.
Strengths and limitations of this study
The fact that observational data were used and other factors may explain the observed reductions in risk. Information on the cost of adopting the closed system was not available but is required to complete the economic argument. The time-dependent covariate of infection was correctly modelled by a state based method; failure to account for timing of infection is an important source of bias. There are few published data on the value of improving infection control in middle income settings where the problem is relatively large and the potential gains substantial.
doi:10.1136/bmjopen-2011-000188
PMCID: PMC3191595  PMID: 22021881
10.  The Working After Cancer Study (WACS): a population-based study of middle-aged workers diagnosed with colorectal cancer and their return to work experiences 
BMC Public Health  2011;11:604.
Background
The number of middle-aged working individuals being diagnosed with cancer is increasing and so too will disruptions to their employment. The aim of the Working After Cancer Study is to examine the changes to work participation in the 12 months following a diagnosis of primary colorectal cancer. The study will identify barriers to work resumption, describe limitations on workforce participation, and evaluate the influence of these factors on health-related quality of life.
Methods/Design
An observational population-based study has been designed involving 260 adults newly-diagnosed with colorectal cancer between January 2010 and September 2011 and who were in paid employment at the time they were diagnosed. These cancer cases will be compared to a nationally representative comparison group of 520 adults with no history of cancer from the general population. Eligible cases will have a histologically confirmed diagnosis of colorectal cancer and will be identified through the Queensland Cancer Registry. Data on the comparison group will be drawn from the Household, Income and Labour Dynamics in Australia (HILDA) Survey. Data collection for the cancer group will occur at 6 and 12 months after diagnosis, with work questions also asked about the time of diagnosis, while retrospective data on the comparison group will be come from HILDA Waves 2009 and 2010. Using validated instruments administered via telephone and postal surveys, data will be collected on socio-demographic factors, work status and circumstances, and health-related quality of life (HRQoL) for both groups while the cases will have additional data collected on cancer treatment and symptoms, work productivity and cancer-related HRQoL. Primary outcomes include change in work participation at 12 months, time to work re-entry, work limitations and change in HRQoL status.
Discussion
This study will address the reasons for work cessation after cancer, the mechanisms people use to remain working and existing workplace support structures and the implications for individuals, families and workplaces. It may also provide key information for governments on productivity losses.
Study Registration
Australian and New Zealand Clinical Trial Registry No. ACTRN12611000530921
doi:10.1186/1471-2458-11-604
PMCID: PMC3163550  PMID: 21798072
11.  The use of economic evaluation in CAM: an introductory framework 
Background
For CAM to feature prominently in health care decision-making there is a need to expand the evidence-base and to further incorporate economic evaluation into research priorities.
In a world of scarce health care resources and an emphasis on efficiency and clinical efficacy, CAM, as indeed do all other treatments, requires rigorous evaluation to be considered in budget decision-making.
Methods
Economic evaluation provides the tools to measure the costs and health consequences of CAM interventions and thereby inform decision making. This article offers CAM researchers an introductory framework for understanding, undertaking and disseminating economic evaluation. The types of economic evaluation available for the study of CAM are discussed, and decision modelling is introduced as a method for economic evaluation with much potential for use in CAM. Two types of decision models are introduced, decision trees and Markov models, along with a worked example of how each method is used to examine costs and health consequences. This is followed by a discussion of how this information is used by decision makers.
Conclusions
Undoubtedly, economic evaluation methods form an important part of health care decision making. Without formal training it can seem a daunting task to consider economic evaluation, however, multidisciplinary teams provide an opportunity for health economists, CAM practitioners and other interested researchers, to work together to further develop the economic evaluation of CAM.
doi:10.1186/1472-6882-10-66
PMCID: PMC2992473  PMID: 21067622
12.  Cost-Effectiveness of a Central Venous Catheter Care Bundle 
PLoS ONE  2010;5(9):e12815.
Background
A bundled approach to central venous catheter care is currently being promoted as an effective way of preventing catheter-related bloodstream infection (CR-BSI). Consumables used in the bundled approach are relatively inexpensive which may lead to the conclusion that the bundle is cost-effective. However, this fails to consider the nontrivial costs of the monitoring and education activities required to implement the bundle, or that alternative strategies are available to prevent CR-BSI. We evaluated the cost-effectiveness of a bundle to prevent CR-BSI in Australian intensive care patients.
Methods and Findings
A Markov decision model was used to evaluate the cost-effectiveness of the bundle relative to remaining with current practice (a non-bundled approach to catheter care and uncoated catheters), or use of antimicrobial catheters. We assumed the bundle reduced relative risk of CR-BSI to 0.34. Given uncertainty about the cost of the bundle, threshold analyses were used to determine the maximum cost at which the bundle remained cost-effective relative to the other approaches to infection control. Sensitivity analyses explored how this threshold alters under different assumptions about the economic value placed on bed-days and health benefits gained by preventing infection. If clinicians are prepared to use antimicrobial catheters, the bundle is cost-effective if national 18-month implementation costs are below $1.1 million. If antimicrobial catheters are not an option the bundle must cost less than $4.3 million. If decision makers are only interested in obtaining cash-savings for the unit, and place no economic value on either the bed-days or the health benefits gained through preventing infection, these cost thresholds are reduced by two-thirds.
Conclusions
A catheter care bundle has the potential to be cost-effective in the Australian intensive care setting. Rather than anticipating cash-savings from this intervention, decision makers must be prepared to invest resources in infection control to see efficiency improvements.
doi:10.1371/journal.pone.0012815
PMCID: PMC2941454  PMID: 20862246
13.  Living Well with Diabetes: a randomized controlled trial of a telephone-delivered intervention for maintenance of weight loss, physical activity and glycaemic control in adults with type 2 diabetes 
BMC Public Health  2010;10:452.
Background
By 2025, it is estimated that approximately 1.8 million Australian adults (approximately 8.4% of the adult population) will have diabetes, with the majority having type 2 diabetes. Weight management via improved physical activity and diet is the cornerstone of type 2 diabetes management. However, the majority of weight loss trials in diabetes have evaluated short-term, intensive clinic-based interventions that, while producing short-term outcomes, have failed to address issues of maintenance and broad population reach. Telephone-delivered interventions have the potential to address these gaps.
Methods/Design
Using a two-arm randomised controlled design, this study will evaluate an 18-month, telephone-delivered, behavioural weight loss intervention focussing on physical activity, diet and behavioural therapy, versus usual care, with follow-up at 24 months. Three-hundred adult participants, aged 20-75 years, with type 2 diabetes, will be recruited from 10 general practices via electronic medical records search. The Social-Cognitive Theory driven intervention involves a six-month intensive phase (4 weekly calls and 11 fortnightly calls) and a 12-month maintenance phase (one call per month). Primary outcomes, assessed at 6, 18 and 24 months, are: weight loss, physical activity, and glycaemic control (HbA1c), with weight loss and physical activity also measured at 12 months. Incremental cost-effectiveness will also be examined. Study recruitment began in February 2009, with final data collection expected by February 2013.
Discussion
This is the first study to evaluate the telephone as the primary method of delivering a behavioural weight loss intervention in type 2 diabetes. The evaluation of maintenance outcomes (6 months following the end of intervention), the use of accelerometers to objectively measure physical activity, and the inclusion of a cost-effectiveness analysis will advance the science of broad reach approaches to weight control and health behaviour change, and will build the evidence base needed to advocate for the translation of this work into population health practice.
Trial Registration
ACTRN12608000203358
doi:10.1186/1471-2458-10-452
PMCID: PMC2927539  PMID: 20678233
14.  Cost-Effectiveness of an Intervention to Reduce Emergency Re-Admissions to Hospital among Older Patients 
PLoS ONE  2009;4(10):e7455.
Background
The objective is to estimate the cost-effectiveness of an intervention that reduces hospital re-admission among older people at high risk. A cost-effectiveness model to estimate the costs and health benefits of the intervention was implemented.
Methodology/Principal Findings
The model used data from a randomised controlled trial conducted in an Australian tertiary metropolitan hospital. Participants were acute medical admissions aged >65 years with at least one risk factor for re-admission: multiple comorbidities, impaired functionality, aged >75 years, recent multiple admissions, poor social support, history of depression. The intervention was a comprehensive nursing and physiotherapy assessment and an individually tailored program of exercise strategies and nurse home visits with telephone follow-up; commencing in hospital and continuing following discharge for 24 weeks. The change to cost outcomes, including the costs of implementing the intervention and all subsequent use of health care services, and, the change to health benefits, represented by quality adjusted life years, were estimated for the intervention as compared to existing practice. The mean change to total costs and quality adjusted life years for an average individual over 24 weeks participating in the intervention were: cost savings of $333 (95% Bayesian credible interval $ -1,932∶1,282) and 0.118 extra quality adjusted life years (95% Bayesian credible interval 0.1∶0.136). The mean net-monetary-benefit per individual for the intervention group compared to the usual care condition was $7,907 (95% Bayesian credible interval $5,959∶$9,995) for the 24 week period.
Conclusions/Significance
The estimation model that describes this intervention predicts cost savings and improved health outcomes. A decision to remain with existing practices causes unnecessary costs and reduced health. Decision makers should consider adopting this program for elderly hospitalised patients.
doi:10.1371/journal.pone.0007455
PMCID: PMC2759083  PMID: 19829702
15.  Cost-Effectiveness of a Telephone-Delivered Intervention for Physical Activity and Diet 
PLoS ONE  2009;4(9):e7135.
Background
Given escalating rates of chronic disease, broad-reach and cost-effective interventions to increase physical activity and improve dietary intake are needed. The cost-effectiveness of a Telephone Counselling intervention to improve physical activity and diet, targeting adults with established chronic diseases in a low socio-economic area of a major Australian city was examined.
Methodology/Principal Findings
A cost-effectiveness modelling study using data collected between February 2005 and November 2007 from a cluster-randomised trial that compared Telephone Counselling with a “Usual Care” (brief intervention) alternative. Economic outcomes were assessed using a state-transition Markov model, which predicted the progress of participants through five health states relating to physical activity and dietary improvement, for ten years after recruitment. The costs and health benefits of Telephone Counselling, Usual Care and an existing practice (Real Control) group were compared. Telephone Counselling compared to Usual Care was not cost-effective ($78,489 per quality adjusted life year gained). However, the Usual Care group did not represent existing practice and is not a useful comparator for decision making. Comparing Telephone Counselling outcomes to existing practice (Real Control), the intervention was found to be cost-effective ($29,375 per quality adjusted life year gained). Usual Care (brief intervention) compared to existing practice (Real Control) was also cost-effective ($12,153 per quality adjusted life year gained).
Conclusions/Significance
This modelling study shows that a decision to adopt a Telephone Counselling program over existing practice (Real Control) is likely to be cost-effective. Choosing the ‘Usual Care’ brief intervention over existing practice (Real Control) shows a lower cost per quality adjusted life year, but the lack of supporting evidence for efficacy or sustainability is an important consideration for decision makers. The economics of behavioural approaches to improving health must be made explicit if decision makers are to be convinced that allocating resources toward such programs is worthwhile.
Trial Registration
This paper uses data collected in a previous clinical trial registered at the Australian Clinical Trials Registry, Australian New Zealand Clinical Trials Registry: Anzcrt.org.au ACTRN012607000195459
doi:10.1371/journal.pone.0007135
PMCID: PMC2744997  PMID: 19779611
16.  Cost effectiveness of antimicrobial catheters in the intensive care unit: addressing uncertainty in the decision 
Critical Care  2009;13(2):R35.
Introduction
Some types of antimicrobial-coated central venous catheters (A-CVC) have been shown to be cost effective in preventing catheter-related bloodstream infection (CR-BSI). However, not all types have been evaluated, and there are concerns over the quality and usefulness of these earlier studies. There is uncertainty amongst clinicians over which, if any, A-CVCs to use. We re-evaluated the cost effectiveness of all commercially available A-CVCs for prevention of CR-BSI in adult intensive care unit (ICU) patients.
Methods
We used a Markov decision model to compare the cost effectiveness of A-CVCs relative to uncoated catheters. Four catheter types were evaluated: minocycline and rifampicin (MR)-coated catheters, silver, platinum and carbon (SPC)-impregnated catheters, and two chlorhexidine and silver sulfadiazine-coated catheters; one coated on the external surface (CH/SSD (ext)) and the other coated on both surfaces (CH/SSD (int/ext)). The incremental cost per quality-adjusted life year gained and the expected net monetary benefits were estimated for each. Uncertainty arising from data estimates, data quality and heterogeneity was explored in sensitivity analyses.
Results
The baseline analysis, with no consideration of uncertainty, indicated all four types of A-CVC were cost-saving relative to uncoated catheters. MR-coated catheters prevented 15 infections per 1,000 catheters and generated the greatest health benefits, 1.6 quality-adjusted life years, and cost savings (AUD $130,289). After considering uncertainty in the current evidence, the MR-coated catheters returned the highest incremental monetary net benefits of AUD $948 per catheter; however there was a 62% probability of error in this conclusion. Although the MR-coated catheters had the highest monetary net benefits across multiple scenarios, the decision was always associated with high uncertainty.
Conclusions
Current evidence suggests that the cost effectiveness of using A-CVCs within the ICU is highly uncertain. Policies to prevent CR-BSI amongst ICU patients should consider the cost effectiveness of competing interventions in the light of this uncertainty. Decision makers would do well to consider the current gaps in knowledge and the complexity of producing good quality evidence in this area.
doi:10.1186/cc7744
PMCID: PMC2689469  PMID: 19284570
17.  Perinatal HIV transmission and the cost-effectiveness of screening at 14 weeks gestation, at the onset of labour and the rapid testing of infants 
Background
Preventing HIV transmission is a worldwide public health issue. Vertical transmission of HIV from a mother can be prevented with diagnosis and treatment, but screening incurs cost. The U.S. Virgin Islands follows the mainland policy on antenatal screening for HIV even though HIV prevalence is higher and rates of antenatal care are lower. This leads to many cases of vertically transmitted HIV. A better policy is required for the U.S. Virgin Islands.
Methods
The objective of this research was to estimate the cost-effectiveness of relevant HIV screening strategies for the antenatal population in the U.S. Virgin Islands. An economic model was used to evaluate the incremental costs and incremental health benefits of nine different combinations of perinatal HIV screening strategies as compared to existing practice from a societal perspective. Three opportunities for screening were considered in isolation and in combination: by 14 weeks gestation, at the onset of labor, or of the infant after birth. The main outcome measure was the cost per life year gained (LYG).
Results
Results indicate that all strategies would produce benefits and save costs. Universal screening by 14 weeks gestation and screening the infant after birth is the recommended strategy, with cost savings of $1,122,787 and health benefits of 310 LYG. Limitations include the limited research on the variations in screening acceptance of screening based on specimen sample, race and economic status. The benefits of screening after 14 weeks gestation but before the onset of labor were also not addressed.
Conclusion
This study highlights the benefits of offering screening at different opportunities and repeat screening and raises the question of generalizing these results to other countries with similar characteristics.
doi:10.1186/1471-2334-8-174
PMCID: PMC2642823  PMID: 19117527
18.  Economic Evaluation and Catheter-related Bloodstream Infections 
Emerging Infectious Diseases  2007;13(6):815-823.
A comprehensive understanding of the economics of preventing catheter-related bloodstream infections is needed.
Catheter-related bloodstream infections are a serious problem. Many interventions reduce risk, and some have been evaluated in cost-effectiveness studies. We review the usefulness and quality of these economic studies. Evidence is incomplete, and data required to inform a coherent policy are missing. The cost-effectiveness studies are characterized by a lack of transparency, short time-horizons, and narrow economic perspectives. Data quality is low for some important model parameters. Authors of future economic evaluations should aim to model the complete policy and not just single interventions. They should be rigorous in developing the structure of the economic model, include all relevant economic outcomes, use a systematic approach for selecting data sources for model parameters, and propagate the effect of uncertainty in model parameters on conclusions. This will inform future data collection and improve our understanding of the economics of preventing these infections.
doi:10.3201/eid1306.070048
PMCID: PMC2792862  PMID: 17553218
Catheterization, central venous catheters, intensive care, costs and cost analysis, decision making; decision support, techniques, models, economic, perspective
19.  Costs of Surgical Site Infections That Appear after Hospital Discharge 
Emerging Infectious Diseases  2006;12(5):831-834.
Data were collected from surgical patients in the hospital and on 4 occasions postdischarge. The incidence of postdischarge surgical site infection was 8.46%. Strong evidence showed that these infections caused minor additional costs, which contradicts existing literature. We discuss why previous studies might have overstated costs.
doi:10.3201/eid1205.051321
PMCID: PMC3374438  PMID: 16704847
costs and cost analysis; surgical wound infection; community health services; economics; patient discharge; hospitalization; dispatch
20.  Re-interpreting the data on the cost and effectiveness of population screening for colorectal cancer in Australia 
Three studies report estimates of the cost and effectiveness of alternate strategies for screening the average-risk Australian population for colorectal cancer. The options considered are faecal occult blood testing, double contrast barium enema, sigmoidoscopy and colonoscopy. At present, there is no consensus over which screening method is optimal by the economic criterion. Also, the existing studies report a mixture of average and incremental cost-effectiveness ratios derived from data collected between 1994 and 2002. We suggest average cost-effectiveness ratios are not useful for decision-making and illustrate how they differ from the preferred incremental cost-effectiveness ratio. We then update the cost data reported in the three studies to 2002 prices and calculate incremental cost-effectiveness ratios where not previously available. Our re-analysis of one study contradicts the conclusions drawn by the authors, who had only calculated average cost-effectiveness ratios. In particular, we find their recommendation of population screening with colonoscopy would cause, annually, between 33 and 1,322 years of life to be lost and between $M17 and $M87 to be wasted. Based on updated cost data and the incremental analysis, our findings indicate that population screening using biennial faecal occult blood testing ($39,459 per life-year gained), annual faecal occult blood testing ($30,556 per life-year gained) and colonoscopy ($26,587 per life-year gained) are cost-effective. Hence, the decision over which method of screening is optimal remains ambiguous across the three studies. We recommend policy-makers choose the study they believe produces the most accurate estimates of cost and health effect, identify their willingness to pay for health benefits and consider other issues relevant to the decision.
doi:10.1186/1743-8462-2-10
PMCID: PMC1173078  PMID: 15904536
21.  Economics and Preventing Hospital-acquired Infection 
Emerging Infectious Diseases  2004;10(4):561-566.
The economics of preventing hospital-acquired infections is most often described in general terms. The underlying concepts and mechanisms are rarely made explicit but should be understood for research and policy-making. We define the key economic concepts and specify an illustrative model that uses hypothetical data to identify how two related questions might be addressed: 1) how much should be invested for infection control, and 2) what are the most appropriate infection-control programs? We aim to make explicit the economics of preventing hospital-acquired infections.
doi:10.3201/eid1004.020754
PMCID: PMC3086182  PMID: 15200842
Cross infection; Infection Control; Economics; Opportunity Cost; Cost-Effectiveness Analysis
22.  Funding grant proposals for scientific research: retrospective analysis of scores by members of grant review panel 
Objective To quantify randomness and cost when choosing health and medical research projects for funding.
Design Retrospective analysis.
Setting Grant review panels of the National Health and Medical Research Council of Australia.
Participants Panel members’ scores for grant proposals submitted in 2009.
Main outcome measures The proportion of grant proposals that were always, sometimes, and never funded after accounting for random variability arising from differences in panel members’ scores, and the cost effectiveness of different size assessment panels.
Results 59% of 620 funded grants were sometimes not funded when random variability was taken into account. Only 9% (n=255) of grant proposals were always funded, 61% (n=1662) never funded, and 29% (n=788) sometimes funded. The extra cost per grant effectively funded from the most effective system was $A18 541 (£11 848; €13 482; $19 343).
Conclusions Allocating funding for scientific research in health and medicine is costly and somewhat random. There are many useful research questions to be addressed that could improve current processes.
doi:10.1136/bmj.d4797
PMCID: PMC3181233  PMID: 21951756
23.  Screening, isolation, and decolonisation strategies in the control of meticillin resistant Staphylococcus aureus in intensive care units: cost effectiveness evaluation 
Objective To assess the cost effectiveness of screening, isolation, and decolonisation strategies in the control of meticillin resistant Staphylococcus aureus (MRSA) in intensive care units.
Design Economic evaluation based on a dynamic transmission model.
Setting England and Wales.
Population Theoretical population of patients on an intensive care unit.
Main outcome measures Infections, deaths, costs, quality adjusted life years (QALYs), incremental cost effectiveness ratios for alternative strategies, and net monetary benefits.
Results All decolonisation strategies improved health outcomes and reduced costs. Although universal decolonisation (regardless of MRSA status) was the most cost effective in the short term, strategies using screening to target MRSA carriers may be preferred owing to the reduced risk of selecting for resistance. Among such targeted strategies, universal admission and weekly screening with polymerase chain reaction coupled with decolonisation using nasal mupirocin was the most cost effective. This finding was robust to the size of intensive care units, prevalence of MRSA on admission, proportion of patients classified as high risk, and precise value of willingness to pay for health benefits. All strategies using isolation but not decolonisation improved health outcomes but costs were increased. When the prevalence of MRSA on admission to the intensive care unit was 5% and the willingness to pay per QALY gained was between £20 000 (€23 000; $32 000) and £30 000, the best such strategy was to isolate only those patients at high risk of carrying MRSA (either pre-emptively or after identification by admission and weekly screening for MRSA using chromogenic agar). Universal admission and weekly screening using polymerase chain reaction based detection of MRSA coupled with isolation was unlikely to be cost effective unless prevalence was high (10% of patients colonised with MRSA on admission).
Conclusions MRSA control strategies that use decolonisation are likely to be cost saving in an intensive care unit setting provided resistance is lacking, and combining universal screening using polymerase chain reaction with decolonisation is likely to represent good value for money if untargeted decolonisation is considered unacceptable. In intensive care units where decolonisation is not implemented, evidence is insufficient to support universal screening for MRSA outside high prevalence settings.
doi:10.1136/bmj.d5694
PMCID: PMC3188660  PMID: 21980062
24.  Is 27 really a dangerous age for famous musicians? Retrospective cohort study 
Objective To test the “27 club” hypothesis that famous musicians are at an increased risk of death at age 27.
Design Cohort study using survival analysis with age as a time dependent exposure. Comparison was primarily made within musicians, and secondarily relative to the general UK population.
Setting The popular music scene from a UK perspective.
Participants Musicians (solo artists and band members) who had a number one album in the UK between 1956 and 2007 (n=1046 musicians, with 71 deaths, 7%).
Main outcome measures Risk of death by age of musician, accounting for time dependent study entry and the number of musicians at risk. Risk was estimated using a flexible spline which would allow a bump at age 27 to appear.
Results We identified three deaths at age 27 amongst 522 musicians at risk, giving a rate of 0.57 deaths per 100 musician years. Similar death rates were observed at ages 25 (rate=0.56) and 32 (0.54). There was no peak in risk around age 27, but the risk of death for famous musicians throughout their 20s and 30s was two to three times higher than the general UK population.
Conclusions The 27 club is unlikely to be a real phenomenon. Fame may increase the risk of death among musicians, but this risk is not limited to age 27.
doi:10.1136/bmj.d7799
PMCID: PMC3243755  PMID: 22187325

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