Indicators of Risk for Dental Caries in Children: A Holistic Approach

BACKGROUND

Dental caries in children is a major public health problem worldwide, with a multitude of determinants acting upon children to different degrees in different communities. The objective of this study was to determine maternal, environmental, and intraoral indicators of dental caries experience in a sample of 6- to 7-y-old children in South East Queensland, Australia.

METHODS

A total of 174 mother-child dyads were recruited for this cross-sectional study from the Griffith University Environments for Healthy Living birth cohort study. Maternal education, employment status, and prepregnancy body mass index were maternal indicators, and annual household income was taken as a proxy for environmental indicators. These were collected as baseline data of the study. Clinical data on children's dental caries experience, saliva characteristics of buffering capacity, stimulated flow rate, and colony-forming units per milliliter of salivary mutans streptococci were collected for the oral health substudy. Univariate analysis was performed with 1-way analysis of variance and chi-square tests. Caries experience was the outcome, which was classified into 4 categories based on the number of carious tooth surfaces. Ordinal logistic regression was used to explore the association of risk indicators with caries experience.

RESULTS

Age (P = 0.021), low salivary buffering capacity (P = 0.001), reduced levels of salivary flow rate (P = 0.011), past caries experience (P = 0.001), low annual household income; <$30,000 (P = 0.050) and <$60,000 (P = 0.033) and maternal employment status (P = 0.043) were associated with high levels of dental caries.

CONCLUSION

These data support the evidence of associations between maternal, environmental, and children's intraoral characteristics and caries experience among children in a typical Western industrialized country. All of these need to be considered in preventative strategies within families and communities.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by clinicians, epidemiologists, and policy makers to identify children who are at risk of developing dental caries. With consideration of costs for treatment for the disease, this information could be used to plan cost-effective and patient-centered preventive care.

Standard vs. intensified management of heart failure to reduce healthcare costs: results of a multicentre, randomized controlled trial

Aims

To determine if an intensified form of heart failure management programme (INT-HF-MP) based on individual profiling is superior to standard management (SM) in reducing health care costs during 12-month follow-up (primary endpoint).

Methods and results

A multicentre randomized trial involving 787 patients (full analysis set) discharged from four tertiary hospitals with chronic HF who were randomized to SM (n = 391) or INT-HF-MP (n = 396). Mean age was 74 ± 12 years, 65% had HF with a reduced ejection fraction (31.4 ± 8.9%) and 14% were remote-dwelling. Study groups were well matched. According to Green, Amber, Red Delineation of rIsk And Need in HF (GARDIAN-HF) profiling, regardless of location, patients in the INT-HF-MP received a combination of face-to-face (home visits) and structured telephone support (STS); only 9% (`low risk') were designated to receive the same level of management as the SM group. The median cost in 2017 Australian dollars (A$1 equivalent to ∼EUR €0.7) of applying INT-HF-MP was significantly greater than SM ($152 vs. $121 per patient per month; P < 0.001), However, at 12 months, there was no difference in total health care costs for the INT-HF-MP vs. SM group (median $1579, IQR $644 to $3717 vs. $1450, IQR $564 to $3615 per patient per month, respectively). This reflected minimal differences in all-cause mortality (17.7% vs. 18.4%; P = 0.848) and recurrent hospital stay (18.6 ± 26.5 vs. 16.6 ± 24.8 days; P = 0.199) between the INT-HF-MP and SM groups, respectively.

Conclusion

During 12-months follow-up, an INT-HF-MP did not reduce healthcare costs or improve health outcomes relative to SM.

Correction to: Recommendations from Two Citizens' Juries on the Surgical Management of Obesity

The spelling of the name of author K. Chalkidou was incorrect in the original article. It is correct here.

An empirical comparison of Markov cohort modeling and discrete event simulation in a capacity-constrained health care setting

OBJECTIVES

To empirically compare Markov cohort modeling (MM) and discrete event simulation (DES) with and without dynamic queuing (DQ) for cost-effectiveness (CE) analysis of a novel method of health services delivery where capacity constraints predominate.

METHODS

A common data-set comparing usual orthopedic care (UC) to an orthopedic physiotherapy screening clinic and multidisciplinary treatment service (OPSC) was used to develop a MM and a DES without (DES-no-DQ) and with DQ (DES-DQ). Model results were then compared in detail.

RESULTS

The MM predicted an incremental CE ratio (ICER) of $495 per additional quality-adjusted life-year (QALY) for OPSC over UC. The DES-no-DQ showed OPSC dominating UC; the DES-DQ generated an ICER of $2342 per QALY.

CONCLUSIONS

The MM and DES-no-DQ ICER estimates differed due to the MM having implicit delays built into its structure as a result of having fixed cycle lengths, which are not a feature of DES. The non-DQ models assume that queues are at a steady state. Conversely, queues in the DES-DQ develop flexibly with supply and demand for resources, in this case, leading to different estimates of resource use and CE. The choice of MM or DES (with or without DQ) would not alter the reimbursement of OPSC as it was highly cost-effective compared to UC in all analyses. However, the modeling method may influence decisions where ICERs are closer to the CE acceptability threshold, or where capacity constraints and DQ are important features of the system. In these cases, DES-DQ would be the preferred modeling technique to avoid incorrect resource allocation decisions.

Engaging the public in healthcare decision-making: results from a Citizens' Jury on emergency care services

BACKGROUND

Policies addressing ED crowding have failed to incorporate the public's perspectives; engaging the public in such policies is needed.

OBJECTIVE

This study aimed at determining the public's recommendations related to alternative models of care intended to reduce crowding, optimising access to and provision of emergency care.

METHODS

A Citizens' Jury was convened in Queensland, Australia, to consider priority setting and resource allocation to address ED crowding. Twenty-two jurors were recruited from the electoral roll, who were interested and available to attend the jury from 15 to 17 June 2012. Juror feedback was collected via a survey immediately following the end of the jury.

RESULTS

The jury considered that all patients attending the ED should be assessed with a minority of cases diverted for assistance elsewhere. Jurors strongly supported enabling ambulance staff to treat patients in their homes without transporting them to the ED, and allowing non-medical staff to treat some patients without seeing a doctor. Jurors supported (in principle) patient choice over aspects of their treatment (when, where and type of health professional) with some support for patients paying towards treatment but unanimous opposition for patients paying to be prioritised. Most of the jurors were satisfied with their experience of the Citizens' Jury process, but some jurors perceived the time allocated for deliberations as insufficient.

CONCLUSIONS

These findings suggest that the general public may be open to flexible models of emergency care. The jury provided clear recommendations for direct public input to guide health policy to tackle ED crowding.

Health services utilization of women following a traumatic birth

This cohort study compared 262 women with high childbirth distress to 138 non-distressed women. At 12 months, high distress women had lower health-related quality of life compared to non-distressed women (EuroQol five-dimensional (EQ-5D) scale 0.90 vs. 0.93, p = 0.008), more visits to general practitioners (3.5 vs. 2.6, p = 0.002) and utilized more additional services (e.g. maternal health clinics), with no differences for infants. Childbirth distress has lasting adverse health effects for mothers and increases health-care utilization.

The role of fathers in child feeding: perceived responsibility and predictors of participation

BACKGROUND

The role of fathers in shaping their child's eating behaviour and weight status through their involvement in child feeding has rarely been studied. This study aims to describe fathers' perceived responsibility for child feeding, and to identify predictors of how frequently fathers eat meals with their child.

METHODS

Four hundred and thirty-six Australian fathers (M age = 37 years, SD = 6 years; 34% university educated) of a 2-5-year-old child (M age = 3.5 years, SD = 0.9 years; 53% boys) were recruited via contact with mothers enrolled in existing research projects or a university staff and student email list. Data were collected from fathers via a self-report questionnaire. Descriptive and hierarchical linear regression analyses were conducted.

RESULTS

The majority of fathers reported that the family often/mostly ate meals together (79%). Many fathers perceived that they were responsible at least half of the time for feeding their child in terms of organizing meals (42%); amount offered (50%) and deciding if their child eats the 'right kind of foods' (60%). Time spent in paid employment was inversely associated with how frequently fathers ate meals with their child (β = -0.23, P < 0.001); however, both higher perceived responsibility for child feeding (β = 0.16, P < 0.004) and a more involved and positive attitude toward their role as a father (β = 0.20, P < 0.001) were positively related to how often they ate meals with their child, adjusting for a range of paternal and child covariates, including time spent in paid employment.

CONCLUSIONS

Fathers from a broad range of educational backgrounds appear willing to participate in research studies on child feeding. Most fathers were engaged and involved in family meals and child feeding. This suggests that fathers, like mothers, should be viewed as potential agents for the implementation of positive feeding practices within the family.

A cost-effectiveness analysis of a telephone-linked care intervention for individuals with Type 2 diabetes

AIM

To assess the cost-effectiveness of an automated telephone-linked care intervention, Australian TLC Diabetes, delivered over 6 months to patients with established Type 2 diabetes mellitus and high glycated haemoglobin level, compared to usual care.

METHODS

A Markov model was designed to synthesize data from a randomized controlled trial of TLC Diabetes (n=120) and other published evidence. The 5-year model consisted of three health states related to glycaemic control: 'sub-optimal' HbA1c ≥58mmol/mol (7.5%); 'average' ≥48-57mmol/mol (6.5-7.4%) and 'optimal' <48mmol/mol (6.5%) and a fourth state 'all-cause death'. Key outcomes of the model include discounted health system costs and quality-adjusted life years (QALYS) using SF-6D utility weights. Univariate and probabilistic sensitivity analyses were undertaken.

RESULTS

Annual medication costs for the intervention group were lower than usual care [

INTERVENTION

£1076 (95%CI: £947, £1206) versus usual care £1271 (95%CI: £1115, £1428) p=0.052]. The estimated mean cost for intervention group participants over five years, including the intervention cost, was £17,152 versus £17,835 for the usual care group. The corresponding mean QALYs were 3.381 (SD 0.40) for the intervention group and 3.377 (SD 0.41) for the usual care group. Results were sensitive to the model duration, utility values and medication costs.

CONCLUSION

The Australian TLC Diabetes intervention was a low-cost investment for individuals with established diabetes and may result in medication cost-savings to the health system. Although QALYs were similar between groups, other benefits arising from the intervention should also be considered when determining the overall value of this strategy.

PRIME: impact of previous mental health problems on health-related quality of life in women with childbirth trauma

We investigated the impact of pre-existing mental ill health on postpartum maternal outcomes. Women reporting childbirth trauma received counselling (Promoting Resilience in Mothers' Emotions; n = 137) or parenting support (n = 125) at birth and 6 weeks. The EuroQol Five dimensional (EQ-5D)-measured health-related quality of life at 6 weeks, 6 and 12 months. At 12 months, EQ-5D was better for women without mental health problems receiving PRIME (mean difference (MD) 0.06; 95 % confidence interval (CI) 0.02 to 0.10) or parenting support (MD 0.08; 95 % CI 0.01 to 0.14). Pre-existing mental health conditions influence quality of life in women with childbirth trauma.

Can post-acute care programmes for older people reduce overall costs in the health system? A case study using the Australian Transition Care Programme

There is an increasing demand for acute care services due in part to rising proportions of older people and increasing rates of chronic diseases. To reduce pressure and costs in the hospital system, community-based post-acute care discharge services for older people have evolved as one method of reducing length of stay in hospital and preventing readmissions. However, it is unclear whether they reduce overall episode cost or expenditure in the health system at a more general level. In this paper, we review the current evidence on the likely costs and benefits of these services and consider whether they are potentially cost-effective from a health services perspective, using the Australian Transition Care Programme as a case study. Evaluations of community-based post-acute services have demonstrated that they reduce length of stay, prevent some re-hospitalisations and defer nursing home placement. There is also evidence that they convey some additional health benefits to older people. An economic model was developed to identify the maximum potential benefits and the likely cost savings from reduced use of health services from earlier discharge from hospital, accelerated recovery, reduced likelihood of readmission to hospital and delayed entry into permanent institutional care for participants of the Transition Care Programme. Assuming the best case scenario, the Transition Care Programme is still unlikely to be cost saving to a healthcare system. Hence for this service to be justified, additional health benefits such as quality of life improvements need to be taken into account. If it can be demonstrated that this service also conveys additional quality of life improvements, community-based programmes such as Transition Care could be considered to be cost-effective when compared with other healthcare programmes.

A mixed treatment comparison of the short-term efficacy of biologic disease modifying anti-rheumatic drugs in established rheumatoid arthritis

BACKGROUND

The short-term efficacy of biological disease modifying anti-rheumatic drugs (bDMARDs) for the treatment of established moderate to severe rheumatoid arthritis (RA) has been demonstrated by various randomized placebo or active treatment controlled trials. However, there is a lack of direct comparison of these agents.

SCOPE

To compare the short-term efficacy of nine bDMARDs - abatacept, adalimumab, anakinra, certolizumab, etanercept, golimumab, infliximab, rituximab and tocilizumab - in patients with established RA.

FINDINGS

A systematic review was conducted to obtain all available efficacy data for each included bDMARD. Medline, EMBASE, and Cochrane clinical trials were searched for trials in patients with RA. Twenty-seven trials were retrieved from a systematic literature search and included in the meta-analysis. Mixed treatment comparison (MTC) techniques were used to perform indirect comparisons. Analyses were conducted to estimate the odds ratio of an ACR20, ACR50, and ACR70 response at approximately six months if treated with a bDMARD compared with placebo or methotrexate. Between-drug comparisons were also made. The analyses were performed including recommended doses only (as per the product information). All drugs except anakinra and golimumab demonstrated a statistically significant advantage compared to control treatment for ACR20 responses. The between-drug comparisons revealed a statistically significant advantage for certolizumab compared to most bDMARDs for ACR20, ACR50 and ACR70 response and for etanercept versus adalimumab and anakinra for ACR20 and ACR50 response, as well as a statistically significant advantage for tocilizumab versus anakinra for ACR50 response.

CONCLUSION

The analyses, using MTC of efficacy of nine bDMARDs suggest that treatment with anakinra is inferior to other bDMARDs and that etanercept and certolizumab may be more effective than other bDMARDs. There are some limitations of our analyses due to MTC assumptions, variations in trial design and the fact that only ACR outcomes at six months were included.

Guidelines for conducting and reporting economic evaluation of fall prevention strategies

Falls in older people result in substantial health burden. Compelling evidence indicates that falls can be prevented. We developed comprehensive guidelines for economic evaluations of fall prevention interventions to facilitate publication of high-quality economic evaluations of the effective strategies and aid decision making.

INTRODUCTION

The importance of economics applied to falls and fall prevention in older people has largely been overlooked. The use of different methodologies to assess the costs and health benefits of the interventions and their comparators and the inconsistent reporting in the studies limits the usefulness of these economic evaluations for decision making. We developed guidelines to encourage and facilitate completion of high-quality economic evaluations of effective fall prevention strategies.

METHODS

We used a generic checklist for economic evaluations as a platform to develop comprehensive guidelines for conducting and reporting economic evaluations of fall prevention strategies. We considered the many challenges involved, particularly in identifying, measuring, and valuing the relevant cost items.

RESULTS

We recommend researchers include cost outcomes and report incremental cost-effectiveness ratios in terms of falls prevented and quality adjusted life years in all clinical trials of fall prevention interventions. Studies should include the following cost categories: (1) implementing the intervention, (2) delivering the comparator group intervention, (3) total health care costs, (4) costs of fall-related health care resource use, and (5) personal and informal carer opportunity costs.

CONCLUSIONS

This paper provides a timely benchmark to promote comparability and consistency for conducting and reporting economic evaluations of fall prevention strategies.

Using videotelephony to support paediatric oncology-related palliative care in the home: from abandoned RCT to acceptability study

Videotelephony (real-time audio-visual communication) has been used successfully in adult palliative home care. This paper describes two attempts to complete an RCT (both of which were abandoned following difficulties with family recruitment), designed to investigate the use of videotelephony with families receiving palliative care from a tertiary paediatric oncology service in Brisbane, Australia. To investigate whether providing videotelephone-based support was acceptable to these families, a 12-month non-randomised acceptability trial was completed. Seventeen palliative care families were offered access to a videotelephone support service in addition to the 24 hours 'on-call' service already offered. A 92% participation rate in this study provided some reassurance that the use of videotelephones themselves was not a factor in poor RCT participation rates. The next phase of research is to investigate the integration of videotelephone-based support from the time of diagnosis, through outpatient care and support, and for palliative care rather than for palliative care in isolation. Trial registration ACTRN 12606000311550.

The effect of introducing radiographer reporting on the availability of reports for Accident and Emergency and General Practitioner examinations: a time-series analysis

This study explores whether the introduction of selectively trained radiographers reporting Accident and Emergency (A&E) X-ray examinations of the appendicular skeleton affected the availability of reports for A&E and General Practitioner (GP) examinations at a typical district general hospital. This was achieved by analysing monthly data on A&E and GP examinations for 1993-1997 using structural time-series models. Parameters to capture stochastic seasonal effects and stochastic time trends were included in the models. The main outcome measures were changes in the number, proportion and timeliness of A&E and GP examinations reported. Radiographer reporting X-ray examinations requested by A&E was associated with a 12% (p=0.050) increase in the number of A&E examinations reported and a 37% (p</=0.001) decrease in the time taken to report on these examinations. Radiographer reporting of A&E X-ray examinations was also associated with a 14% (p=0.067) decrease in the time taken for GP examinations to be reported. That is, radiographer reporting A&E X-ray examinations allowed an increase in the time available to radiologists to report on examinations requested by GPs. An increase in the proportion of GP examinations reported by radiologists was associated with longer reporting times for A&E examinations. In conclusion, selectively trained radiographers reporting on A&E X-ray examinations significantly improved the availability of reports for A&E and GP examinations.

Secondary prevention after PCI: the cost-effectiveness of statin therapy in the Netherlands

BACKGROUND

Little is known about the cost-effectiveness of secondary prevention after percutaneous coronary intervention (PCI). The aim of this study was to estimate the cost-effectiveness of statin therapy.

METHODS

A cost-effectiveness analysis was performed using data from the Lescol Intervention Prevention Study (LIPS). In the LIPS trial, patients with normal-to-moderate hypercholesterolaemia who had undergone a first PCI were randomised to receive either fluvastatin 40 mg twice-daily plus dietary counselling or dietary counselling alone. A Markov model was used to estimate the incremental costs per quality-adjusted life year (QALY) and life year gained (LYG). Costs were based on prices and reimbursed charges, utility data were drawn from literature. Monte Carlo simulations and multivariate analysis were used to assess uncertainty.

RESULTS

Routine statin treatment costs an additional €734 (SD €686) per patient over ten years compared with controls. It resulted in an additional 0.078 (0.047) QALYs or 0.082 (0.041) LYG. The incremental costs per QALY and LYG were €9312 (€14,648) and €8954 (€16,617) respectively. Anticipating a willingness to pay of €20,000 per QALY, there is a 75.1% chance that fluvastatin treatment is cost-effective.

CONCLUSION

Statin therapy with fluvastatin is economically efficient with regard to reducing heart disease in the Netherlands when given routinely to all patients following PCI.

Pertussis vaccination strategies for neonates—an exploratory cost-effectiveness analysis

Hospitalisation and death from pertussis in highly immunised populations largely occurs before the first vaccination at 2 months. A Markov model was constructed to estimate the costs and health consequences of three strategies to reduce pertussis over the first 6 months of an infant's life. Earlier vaccination (at either birth or 1 month in addition to current practice) or vaccination of the parents soon after birth was compared with the current practice of vaccination at 2, 4 and 6 months. The model was populated using data on the incidence and costs from Australia. Disability-adjusted life-years (DALYs) were used as the primary outcome measure. The cost to the Australian public health system was chosen as the economic perspective, and Monte-Carlo simulations were used to accommodate uncertainties in the variables. Vaccination at birth was estimated to cost (S.D.) an additional A$33.21 (A$1.60) per infant and to reduce cases, deaths and DALYs by 45%. Vaccination at 1 month was estimated to cost an additional A$43.24 (A$8.98) per infant and to reduce morbidity by approximately 25%. Parental vaccination at birth was the most expensive alternative, costing an additional A$73.38 (A$4.98) per infant and reducing pertussis morbidity by 38%. The costs per DALY averted were A$330,175 (A$15,461) A$735,994 (A$147,679) and A$787,504 (A$48,075) for the birth, 1 month and parental vaccination strategies, respectively. Changing the estimated factor by which hospitalisations and deaths are under-reported, and the efficacy of early vaccination, had large effects on results. Parental vaccination at birth was most cost-effective where protection persisted for subsequent children. The birth vaccination strategy appears to offer the greatest potential benefit for one-child families, but the efficacy at birth (and 1 month) needs to be established.

A model of traffic crashes in New Zealand

The aim of this study was to examine the changes in the trend and seasonal patterns in fatal crashes in New Zealand in relation to changes in economic conditions between 1970 and 1994. The Harvey and Durbin (Journal of the Royal Statistical Society 149 (3) (1986) 187-227) structural time series model (STSM), an 'unobserved components' class of model, was used to estimate models for quarterly fatal traffic crashes. The dependent variable was modelled as the number of crashes and three variants of the crash rate (crashes per 10,000 km travelled, crashes per 1,000 vehicles, and crashes per 1000 population). Independent variables included in the models were unemployment rate (UER), real gross domestic product per capita, the proportion of motorcycles, the proportion of young males in the population, alcohol consumption per capita, the open road speed limit, and dummy variables for the 1973 and 1979 oil crises and seat belt wearing laws. UERs, real GDP per capita, and alcohol consumption were all significant and important factors in explaining the short-run dynamics of the models. In the long-run, real GDP per capita was directly related to the number of crashes but after controlling for distance travelled was not significant. This suggests increases in income are associated with a short-run reduction in risk but increases in exposure to a crash (i.e. distance travelled) in the long-run. A 1% increase in the open road speed limit was associated with a long-run 0.5% increase in fatal crashes. Substantial reductions in fatal crashes were associated with the 1979 oil crisis and seat belt wearing laws. The 1984 universal seat belt wearing law was associated with a sustained 15.6% reduction in fatal crashes. These road policy factors appeared to have a greater influence on crashes than the role of demographic and economic factors.

An economic evaluation of the Highlands and Islands teledentistry project

A 12-month trial of teledentistry was conducted in two general dental practices (one in the Orkney Islands and one in the Scottish Highlands at Kingussie). The dental practices had a PC-based videoconferencing link, connected by ISDN at 128 kbit/s, to a restorative specialist at a hospital in Aberdeen. Twenty-five patients were recruited into the trial. A cost-minimization analysis was undertaken by comparing the costs of teledentistry with two alternatives: outreach visits, where the specialist regularly visited the remote communities, and hospital visits, where patients in remote communities travelled to hospital for consultation. For Orkney patients, dental teleconsultations cost the National Health Service (NHS) an additional 36 per patient compared with outreach visits, but cost-savings of 270 per patient could be achieved compared with hospital visits. For Kingussie patients, teleconsultations cost the NHS an additional 44 and there were cost-savings of 1.54 compared with outreach visits and hospitals visits, respectively. However, patients incurred additional costs for radiographs and photographs, and the general dental practitioner incurred additional preparation time costs. When the value of patient time was included, there were cost-savings of around 900 per Orkney patient compared with hospital visits, but compared with outreach visits teledentistry cost an additional 180 per patient. Based on the trial data, there were no cost-savings from teledentistry for Kingussie patients, even when the value of time was included. These results were relatively robust in a sensitivity analysis. However, we estimated that the cost-effectiveness of teledentistry would improve with greater familiarity and use of equipment. Benefits and cost-savings would be greatest in island or remote communities, where patients have to travel long distances to hospital for specialist consultations.

Economic evaluation of strategies for the control and management of influenza in Europe

We compared the cost-effectiveness of different strategies for the control and management of influenza for the elderly populations in three European countries (England and Wales, France, Germany). A "no intervention" scenario was compared with six control strategies: opportunistic vaccination (passive recruitment), comprehensive vaccination programmes (active recruitment), 4 weeks chemoprophylaxis course using neuraminidase inhibitors (NIs), 4 weeks chemoprophylaxis course using ion-channel inhibitors (ICIs), early treatment with NIs, and early treatment with ICIs. Vaccination strategies were the most cost-effective. Chemoprophylaxis strategies were highly expensive even under assumptions of optimal timing. Early treatment strategies with antivirals substantially increased demand for GP services and were more expensive than prevention through vaccination.

The cost-effectiveness of varicella vaccine programs for Australia

OBJECTIVE

to examine the cost-effectiveness of three different varicella vaccination programs compared with no vaccination program.

DESIGN

cost-effectiveness study. Simulations of the costs and consequences of chickenpox and the vaccination programs over a 30-year period. Direct (health-care) costs only were used in the simulations.

SETTING

Australia.Participants/subjects: annual birth cohorts of infants (12-months old) and adolescents (12 years old).

INTERVENTIONS

strategy I (no vaccination) was compared with three different varicella vaccination programs: strategy II - all infants; strategy III - adolescents without a history of varicella; and strategy IV ('catch-up')- all infants plus, for the first 11 years, adolescents without a history.

OUTCOME MEASURES

fatalities and hospitalisations for varicella and its complications (encephalitis, pneumonitis, long-term disability).

RESULTS

the average cost per case of chickenpox averted was $64, $530 and $418 in the infant, adolescent and catch-up programs, respectively. The infant program was the most cost-effective of the three. This program could avert 4. 4 million cases, 13,500 hospitalisations and 30 fatalities for chickenpox over a 30-year period. RESULTS were sensitive to the price of the vaccine and the discount rate, but relatively insensitive to changes in vaccine efficacy, coverage rates or vaccine complication rates. Improved accuracy of a negative varicella history in adolescents would substantially reduce the costs of the adolescent and catch-up programs making these programs feasible.

CONCLUSIONS

the infant vaccine program is the preferred program, but the direct costs of any of the vaccination programs considered here are greater than the direct costs of no vaccination program.

The social costs of alcohol abuse in New Zealand

AIMS

This study updates and extends previous New Zealand research on the social costs of alcohol abuse.

DESIGN

This economic cost study used the human capital approach.

SETTING

New Zealand, 1991.

PARTICIPANTS

The total New Zealand population.

MEASUREMENTS

The estimated cost of alcohol abuse for 1 year included direct and indirect costs. Costs such as lost production resulting from premature death and sickness, reduced working efficiency and excess unemployment comprised indirect costs. Direct costs included hospital costs, accident compensation payments, police and justice system costs. A range of social cost estimates was constructed based on various prevalence rates of alcohol abuse, discount rates for lost production and the excess unemployment rate.

FINDINGS

Using a range of assumptions regarding the proportion of each event attributable to alcohol, the sum of social costs ranged from $1045 million to $4005 million in 1991. The direct costs ranged from $341 million to $589 million, respectively.

CONCLUSIONS

While providing an indication of the societal impact of alcohol abuse, these costs pertain to a relatively narrow range of alcohol-related effects. The paper identifies a number of areas where further research is required.

Trends in cycle injury in New Zealand under voluntary helmet use

Twelve months before the wearing of a cycle helmet was to become mandatory in New Zealand, a substantial proportion of cyclists on public roads had 'voluntarily' adopted wearing a helmet. Helmet wearing rates had increased up to 84, 62 and 39% for primary school children, secondary school children, and adults respectively by the end of the period of interest. The purpose of this study was to examine the serious injury trends for three age groups of cyclists: primary school age (5-12 years), secondary school age (13-18 years), and adults (over 18 years) admitted to selected public hospitals between 1980 and 1992; twelve months before the introduction of helmet legislation. Serious injury was defined as 'admitted to hospital' then disaggregated by type of crash and length of stay. Statistical models were constructed that included the proportion of people admitted to hospital with a head injury, then analysed using Poisson regression. Results revealed that the increased helmet wearing percentages has had little association with serious head injuries to cyclists as a percentage of all serious injuries to cyclists for all three groups, with no apparent difference between bicycle only and all cycle crashes. Discussion of the results includes possible explanations for the absence of a decline in the percentage of serious head injury among cyclists as cycle helmet wearing has increased.

The cost-effectiveness of compulsory bicycle helmets in New Zealand

This paper examines the cost-effectiveness for primary school children (age 5-12 years), secondary school children (13-18 years) and adults (over 18 years) of the legislation enacted on 1 January 1994 requiring road-cyclists in New Zealand to wear helmets. The cost to cyclists not in possession of a helmet before they became compulsory of either obtaining one or quitting cycling was compared with the number of deaths and hospitalisations expected to be prevented over the average life of a helmet. Corresponding to Victorian and United States estimates of the efficacy of cycle helmets at preventing serious head injuries, the cost per life saved was $88 379 to $113 744 for primary school children, $694 013 to $817 874 for secondary school children, and $890 041 to $1 014 850 for adults (New Zealand dollars = approximately 0.95 Australian dollars). The cost per hospitalisation avoided was $3304 to $4252, $17 207 to $20 278, and $49 143 to $56 035 respectively. These estimates are extremely sensitive to the estimated efficacy of helmets at protecting cyclists. Mainly anecdotal evidence for New Zealand suggests that they are not to be very effective at preventing serious head injuries; future research into the change in injury patterns as a result of the helmet regulation would be valuable. Nonetheless, the ranking of the abovementioned estimates does not contradict the policy in some parts of the world requiring helmets for children and/or teenagers, but not adults.