Long-term cost-effectiveness of home versus clinic-based management of chronic heart failure: the WHICH? study

Background: The cost-effectiveness of a heart failure management intervention can be further informed by incorporating the expected benefits and costs of future survival.

Methods: This study compared the long-term costs per quality-adjusted life year (QALY) gained from home-based (HBI) vs specialist clinic-based intervention (CBI) among elderly patients (mean age = 71 years) with heart failure discharged home (mean intervention duration = 12 months). Cost-utility analysis was conducted from a government-funded health system perspective. A Markov cohort model was used to simulate disease progression over 15 years based on initial data from a randomized clinical trial (the WHICH? study). Time-dependent hazard functions were modeled using the Weibull function, and this was compared against an alternative model where the hazard was assumed to be constant over time. Deterministic and probabilistic sensitivity analyses were conducted to identify the key drivers of cost-effectiveness and quantify uncertainty in the results.

Results: During the trial, mortality was the highest within 30 days of discharge and decreased thereafter in both groups, although the declining rate of mortality was slower in CBI than HBI. At 15 years (extrapolated), HBI was associated with slightly better health outcomes (mean of 0.59 QALYs gained) and mean additional costs of AU$13,876 per patient. The incremental cost-utility ratio and the incremental net monetary benefit (vs CBI) were AU$23,352 per QALY gained and AU$15,835, respectively. The uncertainty was driven by variability in the costs and probabilities of readmissions. Probabilistic sensitivity analysis showed HBI had a 68% probability of being cost-effective at a willingness-to-pay threshold of AU$50,000 per QALY.

Conclusion: Compared with CBI (outpatient specialized HF clinic-based intervention), HBI (home-based predominantly, but not exclusively) could potentially be cost-effective over the long-term in elderly patients with heart failure at a willingness-to-pay threshold of AU$50,000/QALY, albeit with large uncertainty.     

The relative economic efficiency of urban water utilities in regional New South Wales and Victoria

In recent times the relative economic efficiency of urban water utilities has been neglected as policymakers sought to secure urban water supplies. This paper is an effort to measure the efficiency consequences of a number of recent urban water policy initiatives. Data Envelopment Analysis (DEA) is employed in order to measure the relative technical efficiency of urban water utilities in regional New South Wales (NSW) and Victoria. We show that the almost universal policy of water restrictions is likely to reduce relative efficiency and the typically larger utilities located in Victoria are characterised by a higher degree of managerial efficiency. A number of implications for urban water policy are advanced.     

Regulation versus pricing in urban water policy: the case of the Australian National Water Initiative

The Australian National Water Initiative (NWI) builds on the foundations of earlier water reforms, attempts to correct earlier errors in both policy and its implementation, and seeks to better define some of the policy aims with the benefit of hindsight. However, despite the deliberate effort to improve on earlier reforms, the NWI still embodies a significant economic paradox. Although policymakers have shown their faith in the market insofar as allocating water between competing agricultural interests is concerned, they have not shown the same degree of faith in the ability of urban users to respond to price signals. This paper attempts to shed at least some light on this question by examining the responses of a number of State governments across Australia to the NWI. The paper specifically explores the rationale for non-price regulation in the urban context but challenges the long-term viability of this approach.     

Within trial cost-utility analysis of disease management program for patients hospitalized with atrial fibrillation: results from the SAFETY trial

Abstract

Background: The potential impact of disease management to optimize quality of care, health outcomes, and total healthcare costs across a range of cardiac disease states is unknown.

Methods: A trial-based cost-utility analysis was conducted alongside a randomized controlled trial of 335 patients with chronic, non-valvular AF (without heart failure; the SAFETY Trial) discharged to home from three tertiary referral hospitals in Australia. A home-based disease management intervention (the SAFETY intervention) that involved community-based AF care including home visits was compared to routine primary healthcare and hospital outpatient follow-up (standard management). Bootstrapped incremental cost-utility ratios were computed based on quality-adjusted life-years (QALYs) and total healthcare costs. Cost-effectiveness acceptability curves were constructed to explore the probability of the SAFETY intervention being cost-effective. Sub-group analyses were performed based on age and sex to determine differential cost-effectiveness.

Results: During median follow-up of 1.75?years, the SAFETY intervention was associated with a non-statistically significant increase in QALYs (0.02 per person) and lower total healthcare costs (–$4,375 per person). Although each of these findings were not statistically significant, the SAFETY intervention was found to be dominant (more effective and cost saving) in 58.8% of the bootstrapped iterations and cost-effective (more effective and gains in QALYs achieved at or below $50,000 per QALY gained) in 61.5% of the iterations. Males and those aged less than 78?years achieved greater gains in QALYs and savings in healthcare costs. The estimated value of perfect information in Australia (the monetized value of removing uncertainty in the cost-effectiveness results) was A$51 million, thus demonstrating the high potential gain from further research.

Conclusions: Compared with standard management, the SAFETY intervention is potentially a dominant strategy for those with chronic, non-valvular AF. However, there would be substantial value in reducing the uncertainty in these estimates from further research.

Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12610000221055.     

Greenhouse Gas Emissions from Marine Tours: A Case Study of Australian Tour Boat Operators

This paper estimates the overall and per capita energy costs and GHG contributions associated with tour boat operations in Australia, a country with a 35,000 km coastline and world class marine attractions. Using a comprehensive database of Australian tour boat operators, 145 face-to-face interviews or completed postal survey questionnaires and 45 in- situ audits, the overall GHG emissions for this industry sector was estimated conservatively at 70,000 tons CO2-e or 0.1% of the transport sector in Australia, the fastest growing sector in terms of GHG outputs. On average, this translated into an extra 61 kg CO2-e per tourist if their travel itineraries included a trip on a boat with a diesel engine, or 27 kg CO2-e for a trip on a boat with a petrol engine – the equivalent of a single person driving 140 km or 300 km, respectively, in a standard passenger vehicle. Information obtained from Australian tour boat operators, however, indicated a range of technical and operational opportunities for reducing GHG emissions. In the light of Australia’s anticipated growth in domestic and international visitors, the importance of reducing tour boat GHG outputs, is stressed.     

How ‘exact’ are exact measures of welfare loss?

This paper examines the sensitivity of exact measures of welfare loss to changes in the assumed form of the underlying utility function.     

Surface mining of coal: efficiency of US interior mines

In this paper the relative efficiency in surface mining of US interior coal is investigated. A nonparmetric, non-stochasitic method is applied to 186 observations and esch firm's efficiency is calculated relative to the piecewise llinesr frontier technology. In adition, three sources of inefficiency are identified, namely: Scale, congestion and purely technical inefficiency. The outcome of the study shows among other things that on the average, captive mines are more efficient than non-captive mines, and that unionized mines are more efficient than non-unionized mines.