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1.  Why do multi-attribute utility instruments produce different utilities: the relative importance of the descriptive systems, scale and ‘micro-utility’ effects 
Quality of Life Research  2015;24(8):2045-2053.
Health state utilities measured by the major multi-attribute utility instruments differ. Understanding the reasons for this is important for the choice of instrument and for research designed to reconcile these differences. This paper investigates these reasons by explaining pairwise differences between utilities derived from six multi-attribute utility instruments in terms of (1) their implicit measurement scales; (2) the structure of their descriptive systems; and (3) ‘micro-utility effects’, scale-adjusted differences attributable to their utility formula.
The EQ-5D-5L, SF-6D, HUI 3, 15D and AQoL-8D were administered to 8,019 individuals. Utilities and unweighted values were calculated using each instrument. Scale effects were determined by the linear relationship between utilities, the effect of the descriptive system by comparison of scale-adjusted values and ‘micro-utility effects’ by the unexplained difference between utilities and values.
Overall, 66 % of the differences between utilities was attributable to the descriptive systems, 30.3 % to scale effects and 3.7 % to micro-utility effects.
Results imply that the revision of utility algorithms will not reconcile differences between instruments. The dominating importance of the descriptive system highlights the need for researchers to select the instrument most capable of describing the health states relevant for a study.
Reconciliation of inconsistent utilities produced by different instruments must focus primarily upon the content of the descriptive system. Utility weights primarily determine the measurement scale. Other differences, attributable to utility formula, are comparatively unimportant.
PMCID: PMC4493939  PMID: 25636660
MAU instruments; Cost-utility analysis; Utility
2.  Validity and Reliability of the Assessment of Quality of Life (AQoL)-8D Multi-Attribute Utility Instrument 
The Patient  2013;7(1):85-96.
The purpose of this paper was to report tests of the validity and reliability of a new instrument, the Assessment of Quality of Life (AQoL)-8D, which was constructed to improve the evaluation of health services that have an impact upon the psychosocial aspects of the quality of life.
Australian and US data from a large multi-instrument comparison survey were used to conduct tests of convergent, predictive and content validity using as comparators five other multi-attribute utility (MAU) instruments—the EQ-5D, SF-6D, Health Utilities Index (HUI) 3, 15D and the Quality of Well-Being (QWB)—as well as four non-utility instruments—the SF-36 and three measures of subjective well-being (SWB). A separate three part Australian survey was used to assess test–retest reliability.
Results indicate that AQoL-8D correlates more highly with both the SWB instruments and the psychosocial dimensions of the SF-36, and that it is similar to the other MAU instruments in terms of its convergent and predictive validity. The second Australian survey demonstrated high test–retest reliability.
The results indicate that the AQoL-8D is a reliable and valid instrument which offers an alternative to the MAU instruments presently used in economic evaluation studies, and one which is particularly suitable when psychosocial elements of health are of importance.
PMCID: PMC3929769  PMID: 24271592
3.  Steering without navigation equipment: the lamentable state of Australian health policy reform 
Commentary on health policy reform in Australia often commences with an unstated logical error: Australians' health is good, therefore the Australian Health System is good. This possibly explains the disconnect between the options discussed, the areas needing reform and the generally self-congratulatory tone of the discussion: a good system needs (relatively) minor improvement.
This paper comments on some issues of particular concern to Australian health policy makers and some areas needing urgent reform. The two sets of issues do not overlap. It is suggested that there are two fundamental reasons for this. The first is the failure to develop governance structures which promote the identification and resolution of problems according to their importance. The second and related failure is the failure to equip the health services industry with satisfactory navigation equipment - independent research capacity, independent reporting and evaluation - on a scale commensurate with the needs of the country's largest industry. These two failures together deprive the health system - as a system - of the chief driver of progress in every successful industry in the 20th Century.
Concluding comment is made on the National Health and Hospitals Reform Commission (NHHRC). This continued the tradition of largely evidence free argument and decision making. It failed to identify and properly analyse major system failures, the reasons for them and the form of governance which would maximise the likelihood of future error leaning. The NHHRC itself failed to error learn from past policy failures, a key lesson from which is that a major - and possibly the major - obstacle to reform, is government itself. The Commission virtually ignored the issue of governance. The endorsement of a monopolised system, driven by benevolent managers will miss the major lesson of history which is illustrated by Australia's own failures.
PMCID: PMC2791101  PMID: 19948044
4.  Treatment costs and priority setting in health care: A qualitative study 
The aim of this study is to investigate whether the public believes high cost patients should be a lower priority for public health care than low cost patients, other things being equal, in order to maximise health gains from the health budget. Semi-structured group discussions were used to help participants reflect critically upon their own views and gain exposure to alternative views, and in this way elicit underlying values rather than unreflective preferences. Participants were given two main tasks: first, to select from among three general principles for setting health care priorities the one that comes closest to their own views; second, to allocate a limited hospital budget between two groups of imaginary patients. Forty-one people, varying in age, occupation, income and education level, participated in a total of six group discussions with each group comprising between six and eight people.
After discussion and deliberation, 30 participants rejected the most cost-effective principle for setting priorities, citing reasons such as 'moral values' and 'a personal belief that we shouldn't discriminate'. Only three participants chose to allocate the entire hospital budget to the low cost patients. Reasons for allocating some money to inefficient (high cost) patients included 'fairness' and the desire to give all patients a 'chance'.
Participants rejected a single-minded focus on efficiency – maximising health gains – when setting priorities in health care. There was a concern to avoid strategies that deny patients all hope of treatment, and a willingness to sacrifice health gains for a 'fair' public health system.
PMCID: PMC2685807  PMID: 19416546
5.  Increasing the options for reducing adverse events: Results from a modified Delphi technique 
The aim of this paper is to illustrate a simple method for increasing the range of possible options for reducing adverse events in Australian hospitals, which could have been, but was not, adopted in the wake of the landmark 1995 'Quality in Australian Health Care' study, and to report the suggestions and the estimated lapse time before they would impact upon mortality and morbidity.
The study used a modified Delphi technique that first elicited options for reducing adverse events from an invited panel selected on the basis of their knowledge of the area of adverse events and quality assurance. Initial suggestions were collated and returned to them for re-consideration and comment.
Completed responses from both stages were obtained from 20 of those initially approached. Forty-one options for reducing AEs were identified with an average lapse time of 3.5 years. Hospital regulation had the least delay (2.4 years) and out of hospital information the greatest (6.4 years).
Following identification of the magnitude of the problem of adverse events in the 'Quality in Australian Health Care' study a more rapid and broad ranging response was possible than occurred. Apparently viable options for reducing adverse events and associated mortality and morbidity remain unexploited.
PMCID: PMC2596159  PMID: 19014562
6.  Vision and Quality of Life: Development of Methods for the VisQoL Vision-Related Utility Instrument 
Ophthalmic Epidemiology  2008;15(4):218-223.
To describe the methods and innovations used in constructing the VisQoL, a vision-related utility instrument for the health economic evaluation of eye care and rehabilitation programs.
The VisQoL disaggregates vision into six items. Utilities were estimated for item worst responses (the worst level for each item, with all other items at their best level) and VisQoL all-worst responses (all items at their worst level) using the time trade-off procedure. Time trade-off questions require people to imagine living a fixed number of years with a particular health condition and then indicate how many of those years of life they would be willing to trade to have perfect health. Where respondents indicated a health state was “worse than death” negative utilities were estimated. Time trade-off questions minimized the “focusing effect,” which occurs if respondents discount the fact that all other aspects of health are at their best when answering questions, by using pictorial and verbal aids.
Item utilities were combined using a multiplicative model, and VisQoL model utilities placed on a scale where 0.00 and 1.00 represent full health and death, respectively. The VisQoL allows utilities to be calculated for a wide range of vision-related conditions.
The 6-item VisQoL has excellent psychometric properties and is specifically designed to be sensitive to vision-related quality of life. It is the first instrument to permit the rapid estimation of utility values for use in economic evaluations of vision-related programs.
PMCID: PMC2562021  PMID: 18780254
Vision-related quality of life; utility instrument; cost-utility analysis; economic evaluation; time trade-off
7.  Priorities of health policy: cost shifting or population health 
This paper is an edited version of an invited paper submitted to the Australian Health Care Summit on 17–19 August 2003. It comments upon the policies which have dominated recent debate and contrasts their importance with the importance of five issues which have received relatively little attention.
Policy is usually a response to identified problems and the paper examines the nature and size of the problems which heave led to recent policy initiatives. These are contrasted with the magnitude and potential cost effectiveness policies to address the problems in five areas of comparative neglect.
It is argued that recent and proposed changes to the financing and delivery of health services in Australia have focused upon issues of relatively minor significance while failing to address adequately major inequities and system deficiencies.
There is a need for an independent review of the health system with the terms of reference focusing attention upon large system-wide failures.
PMCID: PMC548139  PMID: 15679895

Results 1-7 (7)