Mindfulness-based interventions are effective in supporting a range of mental health outcomes for breast cancer survivors, yet they are not routinely offered as part of cancer care in Australia. Economic evaluations can support uptake decisions but are often limited by lack of context specific information on outcomes. This study conducted structured stakeholder engagement to inform a meta-analysis to generate relevant effect estimates of mindfulness-based interventions for breast cancer survivors. A literature review identified seven studies published since 2007. A workshop was convened to present information on the study population and characteristics of the mindfulness-based interventions to clinical experts to consider the relevance of the study populations to the local population and the impact of intervention characteristics on published effect estimates. Responses informed the inclusion of relevant primary studies and subgroup meta-analyses based on important elicited differences in intervention characteristics. Structured stakeholder engagement provided context- and intervention-specific insights on factors expected to affect the relevance, feasibility and effectiveness of mindfulness-based interventions in the local context. These insights informed exclusion criteria for primary studies and relevant subgroups for meta-analyses, including an additional 6-hr session, encouragement of home practice and instructor training and experience. This paper outlines a systematic method for contextualising published evidence for a specific context through structured stakeholder engagement. It explores strategies to address uncertainties, including broadening review criteria for meta-regression, expert elicitation to refine effect estimates and the use of economic evaluation to evaluate the magnitude of incremental effects required to demonstrate cost-effectiveness. This study is not preregistered.

Background: Minimally invasive methods for liver resection operations have increased throughout the world. We aimed to determine the trends and cost differences in liver resections conducted by open and laparoscopic approaches at a teaching hospital in South Australia. Methods: We conducted a retrospective analysis of 284 liver resections (247 open (OLR); 37 laparoscopic (LLR); subgroup analysis of 135 major and 149 minor) at Flinders Medical Centre between the 2013/14 and 2021/22 financial years. Trends were calculated using Mann Kendall and statistical analysis was conducted using the Welch t-test. Results: 87% of all resections, 98% major, and 77% of minor resections were OLRs. There was a significant decrease in the number of liver resections in total (tau = -0.686, p<0.05) and OLR (tau = -0.817, p < 0.05). OLR had a significantly higher length of stay (8.17±6.34days) vs. LLR(4.35±3.4days) (p<0.001) in total and for minor resections (4.30±3.43 days vs 7.45±5.05 days, p<0.001). OLR also had a significantly higher total cost ($42,873±20182vs.$23,958±14,700,p<0.001) in total and minor resections ($21,982±10,344 vs.$38,210±16,936, p<0.001). Operating room (OR) was the largest cost bucket in total and subgroup analysis. LLR had a significantly lower OR cost in total ($9,079±5,160vs$14,238±5,739, p<0.001) and in minor resections ($8,891±3,671 VS. 12,225±4,794, p<0.001) Conclusions: Over the study period there has been a decrease in the total number of liver resections, especially OLR. LLR can reduce costs in appropriately selected patients.

BACKGROUND:Barrett's esophagus is the known precursor to esophageal adenocarcinoma (EAC), a cancer with poor prognosis. While endoscopic surveillance detects early dysplasia and prevents progression, most Barrett's esophagus patients do not progress to EAC, leading to invasive and costly surveillance. This study aimed to identify cost-effective endoscopic surveillance strategies by risk stratifying patients based on Barrett's esophagus segment length and sex. METHODS:A Markov cohort model was developed to simulate the natural history of Barrett's esophagus to EAC. The model assessed 85 surveillance strategies and varied endoscopy intervals from 2 to 10 years for nondysplastic Barrett's esophagus and 6-12 months for dysplasia. Risk stratification was based on segment length (≤ 2 and ≤ 3 cm) and sex. Costs, utilities and transition probabilities were derived from published literature and clinical databases. Deterministic and probabilistic sensitivity analyses were performed, and cost-effectiveness was evaluated from a third-party payer perspective using a threshold of AU$50 000/QALY (2023 US dollars 35 945/QALY). RESULTS:The most cost-effective strategy was biennial surveillance for long-segment BE (> 2 cm) and 12-month surveillance for LGD, excluding surveillance in low-risk patients (ICER US$23 737/QALY). Risk-based surveillance consistently outperformed nonstratified strategies. Sensitivity analyses confirmed the robustness of the model, with key drivers being transition rates and endoscopy costs. CONCLUSION:We identified cost-effective risk-stratified endoscopic surveillance strategies for Barrett's esophagus, particularly when excluding low-risk patients. Tailored risk-guided surveillance strategies could improve resource allocation and clinical outcomes in managing Barrett's esophagus. The conserved resources can then be utilized to identify high-risk individuals in the community.

Background: Emergency departments (EDs) globally face sustained pressure from rising demand, workforce shortages, and increasing clinical complexity. Virtual EDs offer a mechanism for reducing avoidable in-person presentations and improving system efficiency, but whole-of-system economic evidence is lacking. We evaluated the costs and consequences of the Victorian Virtual Emergency Department (VVED) during its first two years as a statewide service. Methods: We conducted a cost-consequence analysis using a decision tree model, incorporating linked administrative data from 276,067 VVED consultations across two financial years (FY22–23: n=104,757; FY23–24: n=171,310). Counterfactual pathways were estimated via structured expert elicitation with six senior emergency physicians. Outcomes included ambulance capacity generated, ramping events averted, ED cubicle hours freed, inpatient bed days avoided, and averted costs, analysed across nine referral pathways. Sensitivity analyses examined uncertainty in counterfactual probabilities, length of stay, and observed hospital attendance. Findings: The VVED generated 19,107 ambulance hours and averted 9,998 ramping events in FY22–23, rising to 38,684 hours and 16,007 events in FY23–24. ED occupancy equivalent to 21 and 33 cubicles per year was avoided, alongside 65 and 113 inpatient bed equivalents respectively. Averted ED and inpatient costs were AUD$27m and AUD$32m in FY22–23, rising to AUD$45m and AUD$58m in FY23–24, against total program costs of AUD$29·4m and AUD$50·2m. Gross program cost per ramping event averted was AUD$2,936 (FY22–23) and AUD$3,133 (FY23–24). Residential aged care and ambulance-linked pathways generated the greatest system benefit per dollar invested. Interpretation: The VVED delivers substantial and growing system-level benefits, including reduced ambulance ramping, freed emergency and inpatient capacity, and favourable gross program cost per outcome ratios. These findings support investment in virtual emergency care as a sustainable complement to physical ED services, with funding models needing to evolve to reflect virtual care's growing role in routine service delivery.

Healthcare costs not subsidized by the government and are covered by patients, are known as out-of-pocket healthcare expenditure (OOPHE). In Australia, OOPHE disproportionately impacts Aboriginal households, particularly in rural and remote regions. Currently no patient reported measures (PRM) to assess OOPHE exist, despite being an identified priority in Aboriginal communities. This study developed and psychometrically evaluated (validity and test-retest reliability) of an OOPHE PRM for Aboriginal households in outer regional to remote areas. This Aboriginal led study was governed by an Aboriginal Governance Group, which involved a 4-stage process: (i) identification of community-derived OOPHE themes; (ii) item development and expert judgment quantification; (iii) exploratory factor analysis (EFA) to determine factor structure through pilot testing with Aboriginal participants; and (iv) assessment of reliability and stability through test-retest methods. Stage 1 identified OOPHE themes (i.e. barriers, financial strain), informing development of a 15 item PRM in Stage 2. In Stage 3, 39 Aboriginal participants completed Test 1, with EFA revealing a two-factor model; Factor 1 (8 items, internal consistency = 0.91) and Factor 2 (6 items, internal consistency = 0.85). In Stage 4, 32 participants completed Test 2, with over 60% of items showing substantial to perfect agreement (κ = 0.61-0.87) and scale-level reliability as good to excellent (ICC = 0.75-0.92). Two items performed poorly and were removed, resulting in a final 13-item PRM. The OOPHE PRM demonstrates promising psychometric properties as a culturally grounded measure of OOPHE burden among Aboriginal families, supporting advocacy for equitable policy, funding, and health system reform.

INTRODUCTION:Recognising and acting on the connection to Country as a determinant of Indigenous peoples' well-being is necessary to improve health inequities. Indigenous Australians experience a greater burden of chronic liver disease and poorer outcomes due to ongoing impacts of colonisation across determinants of health. This is exacerbated by a gradient in health outcomes based on remoteness, lack of specialist healthcare services and barriers to access. Our research aims to explore better ways to provide chronic liver disease screening and surveillance for very remote Indigenous Australian communities using non-invasive technologies On-Country. METHODS AND ANALYSIS:Using an innovative combination of Indigenous and Quantitative research methodologies, this project involves 11 communities across four very remote sites in South Australia and Western Australia. The study comprises three parts: (1) site engagement with Aboriginal health services and remote communities; (2) a 12-month liver check (screening) phase and (3) a 24-month liver monitoring (surveillance) phase. The liver monitoring phase will use a stepped-wedge randomised controlled trial design where sites will have usual hepatocellular carcinoma (HCC) monitoring for a period of between 6 and 18 months and then On-Country monitoring for a period of between 6 and 18 months depending on treatment-sequence allocation. Recommended HCC monitoring involves 6 monthly liver ultrasounds and serum alpha-fetoprotein as per the site's usual care processes, where participants travel to regional centres for liver ultrasound. On-Country monitoring will involve liver ultrasound and serum tumour markers provided On-Country every 6 months. The primary outcome is the difference in adherence to surveillance On-Country compared with usual care. In addition to statistical and health economic methods, yarning circles have been incorporated to explore participant experiences, their knowledge of liver disease and views about the On-Country monitoring. ETHICS AND DISSEMINATION:This study was granted ethics approval from the relevant national and state Aboriginal Health Research Ethics Committees. Findings will be reported to all participants and will be disseminated to the broader community and local health services. Translation of outcomes will be supported by key Indigenous Australian and healthcare stakeholders, including peak health bodies and consumer groups. Dissemination with the academic community will be through peer-reviewed publications and presentations at relevant conferences. TRIAL REGISTRATION NUMBER:ACTRN12625000256471.

Narrow-spectrum antimicrobials are likely to drive fewer antimicrobial resistances. However, they may be more expensive than broad-spectrum alternatives. To determine the preferences of antimicrobial stewardship (AMS) experts regarding antimicrobial choice relative to relevant pharmacological and economic attributes, and how those attributes impact their willingness-to-pay for narrow-spectrum of activity. Two discrete choice experiments (DCEs), consisting of six pharmacological and economic attributes, were administered via an online survey to Australian infectious disease physicians, clinical microbiologists and hospital AMS pharmacists. Respondents were asked to complete each DCE from a public hospital perspective, assuming 100 or 1000 patients would be treated each year, respectively. A conditional logit model was used to analyse the DCE data. 155 respondents participated in one or both DCEs. Antimicrobial price, spectrum of activity, administration route, and public funding significantly affected drug choice in both scenarios (p < 0.001). Whether the antimicrobial was a novel class did not significantly impact choice. As the price of a narrow-spectrum antimicrobial increased, it became less preferred compared to a broad-spectrum cheaper alternative. With all other attributes being equal, participants were willing to pay an additional AU862 for the narrow-spectrum option (95

OBJECTIVE:We measured multidisciplinary staff perceptions of the working environment, attitudes to telemedicine and the experience of working in a virtual emergency department (ED) to permit comparison with studies of physical EDs. METHODS:In September 2024, we conducted an online survey of 63 staff in a South Australian virtual ED. The survey comprised the Working Environment Scale (WES-10) and questions assessing attitudes to telemedicine and open-ended questions on attractors and challenges to work. Descriptive statistics and non-parametric inferential statistics were used to compare responses between professions; content analysis was conducted on open-ended data. RESULTS:The response rate was 52% (n = 33, comprising 5 clerical, 16 doctors, 11 nurses and 1 paramedic). The WES-10 scores were (median, interquartile range): Self-realisation (3.6, 3.2-4.3), Workload (3.0, 2.4-3.0), Conflict (1.5, 1.0-2.0) and Nervousness (1.5, 1.0-2.0). We identified inconsistencies in the scoring of previous studies of the physical ED working environment that complicate comparison, although the results suggest that the virtual ED is viewed at least as positively as the physical ED, particularly for Self-realisation. Staff had generally very positive attitudes towards telemedicine, except for future plans for professional development and preference for virtual care. Delivering novel care and having a positive workplace culture were the main attractions to working at the virtual ED, whereas limitations in assessing patients were the main challenge. CONCLUSIONS:Virtual ED staff viewed their workplaces and telemedicine positively and were attracted to the delivery of a novel form of healthcare. Greater consistency of WES-10 measurement is necessary.

Barrett's esophagus is the precursor to esophageal adenocarcinoma. Esophageal adenocarcinoma detected from endoscopic surveillance programs accounts for <10% of all cases, suggesting majority of patients with Barrett's esophagus are likely unaccounted for. Previous observational studies have estimated the observed prevalence of Barrett's esophagus to be approximately 1%, but others suggest may be an underestimate. The aim of this study was twofold: (i) calculate lifetime risk of esophageal adenocarcinoma and (ii) estimate overall and age-specific prevalence of Barrett's esophagus. A tree cohort model was created for progression to esophageal adenocarcinoma from birth to death (100 years) for USA and Australian population. Lifetime risk of esophageal cancer and adenocarcinoma were necessary for calculating Barrett's esophagus prevalence. The model incorporated age- and sex-specific incidence data from national cancer registries: the Australian Institute of Health and Welfare and the Surveillance, Epidemiology, and End Results database for the USA. The model was calibrated using an optimization algorithm, which matched progression rates from Barrett's esophagus to esophageal adenocarcinoma with known national cancer data. A Monte Carlo simulation, with 10,000 iterations, was conducted to derive error margins. Estimates of age-specific and overall prevalence of Barrett's esophagus in the population were generated through a similar process. Results: The lifetime risk of esophageal cancer and adenocarcinoma in USA non-Hispanic White population was 0.56% and 0.36%, respectively, while it was somewhat higher at 0.81% and 0.61% (range 0.57%-0.65%) in the Australian population. Estimated overall prevalence of Barrett's esophagus was ~3% (±0.3%) and ~ 5.4% (±0.6%) in USA White and Australian populations (male and female). Prevalence for age brackets was estimated at 0.06% (±0.02%), 1.6% (±0.7%), 3.2% (±1.3%), 8% (±3%), and 12% (±4%) for USA, and 0.05% (±0.02%), 0.9% (±0.5%), 2.8% (±1.2%), 7% (±3%), and 12% (±4%) for Australian population for ages 0-29, 30-44, 45-59, 60-74, and 75+, respectively. Observed estimates of Barrett's esophagus prevalence are likely lower than projected overall prevalence. This study also presents age-specific prevalence estimates of Barrett's esophagus, which are key in developing screening programs for esophageal adenocarcinoma.

Discrete event simulation (DES) provides enhanced flexibility over modelling techniques that have been traditionally used for assessing health-economic outcomes, making it a particularly interesting technique for modelling complex clinical pathways. Discrete event simulation also facilitates consideration of resources and capacity constraints, making it suitable for addressing a wide range of research questions in health care and beyond. However, those unfamiliar with DES often perceive it to be more complex compared to traditional health-economic modelling techniques, such as state-transition modelling. To address this perceived complexity, this tutorial provides a detailed illustration of implementing DES in the open-source R software using the simmer package, through a case study in colon cancer. The tutorial is aimed at those who have a conceptual model that they want to implement as a DES in R, and are looking for practical guidance. It discusses methodological aspects related to DES and individual-level modelling in general that have not been extensively covered in literature, the conceptual model structure and corresponding pseudocode, data analysis, model implementation, and the deterministic and probabilistic analysis of the model. The documented code provides all building blocks required to develop a wide range of DES models in R using the simmer package.

Aims:Spontaneous cardioversion (SCV) is commonly observed in patients presenting to emergency departments (EDs) with primary atrial fibrillation (AF). Predicting SCV could facilitate timely discharge and avoid costly admissions. We sought to evaluate whether SCV could be predicted using artificial intelligence-enabled electrocardiograms (AI-ECGs) and whether this could produce cost savings. Methods and results:We recruited patients presenting to EDs with primary AF throughout 2022-23. Patients were excluded if the outcome of their AF episode was unclear, or the ECG was not accessible. Spontaneous cardioversion prediction was attempted using ResNet50, EfficientNet, and DenseNet convolutional neural network (CNN) architectures and subsequently an ensemble learning model. We then performed a cost-minimization analysis to estimate the cost effect of a prediction-guided 'wait-and-see' protocol. There were 1159 presentations to the ED, of which 502 had sufficient data for inclusion. The median age was 74.0 years and 54.0% were women. Spontaneous cardioversion occurred in 227 (45.2%) patients and was more frequent in younger patients (P < 0.001). The ensemble learning model outperformed individual CNNs, achieving an accuracy of 69.7% (SD 5.91) and a receiver operating characteristic area under the curve (ROC AUC) of 0.742 (SD 0.037) with a sensitivity and specificity of 0.736 (SD 0.068) and 0.657 (SD 0.150), respectively. The per patient cost was $4681 if all patients were admitted, which reduced to $3398 with a prediction-guided 'wait-and-see' protocol with a 33.3% reduction in overall hospitalization. Conclusion:Artificial intelligence-enabled electrocardiogram can predict SCV in patients presenting to EDs with primary AF, and a prediction-guided 'wait-and-see' protocol utilizing AI-ECG could lead to substantial cost savings and reduced hospitalization.

Although early health technology assessment (HTA) is increasingly being used to guide and inform decisions on product development, a consensus definition is currently lacking. A working group under the HTA International Society was established to develop a consensus-based definition of early HTA. The working group developed a definition using an iterative process that comprised five stages of work and included a two-round Delphi survey with 133 respondents in the first and 99 respondents in the second round of the survey, with various backgrounds and levels of expertise. Following this process, the working group reached the first consensus-based definition of early HTA, which is an HTA conducted to inform decisions about subsequent development, research, and/or investment by explicitly evaluating the potential value of a conceptual or actual health technology. In total, 86 (87 percent) of the 99 panelists who participated in the second round of the Delphi survey either strongly agreed or agreed with this definition. This consensus definition represents an important milestone in early HTA. It will enhance the uniformity of terminology, increasing the visibility of research and policy in this field. We also hope that it will act as a catalyst sparkling further research and developments in this discipline.

Introduction Post COVID-19 condition is a debilitating illness with over 200 symptoms across 10 organ systems and is presently impacting millions worldwide. The National Institute for Health and Care Excellence recommends a multidisciplinary treatment approach including person-centred self-management strategies, however evidence for specific programs is lacking. The Take Charge intervention is a person-centred, self-management rehabilitation approach that has been effective in recovery after stroke, but not yet tested in post COVID-19 condition.Methods & analysis A prospective, single-centre, parallel, 2 group, mixed methods, randomized controlled trial with embedded process evaluation of the Take Charge intervention in individuals living with post COVID-19 condition. Participants will be at least 18 years of age, have a confirmed diagnosis of post COVID-19 condition with ongoing symptoms, and be known to a hospital clinic for assessment and treatment of patients with post-acute sequelae of COVID-19. The primary outcomes are the Modified COVID-19 Yorkshire Rehabilitation Scale and the COVID-19 Core Outcome Measure for Recovery. The secondary outcomes include physical and self-report measures, and feasibility measures. Qualitative interviews will also be conducted to understand the clinicians’ and participants’ experiences. Statistical analysis will be performed on an intention-to-treat basis using a multivariate mixed-effect linear regression model.Ethics & dissemination This study adheres to the Declaration of Helsinki. This study was approved by the Southern Adelaide Clinical Human Research Ethics Committee (approval number: 2022/SSA00695/OFR: 219.22, protocol version 3.3 19 February 2024). The results will be disseminated in peer-reviewed journals, conference presentations, and media.

Background Cancer survivors have a broad range of supportive care needs that are not consistently managed in general practice. Understanding the barriers primary healthcare providers face in providing high quality supportive care is crucial for improving the delivery of supportive care in general practice. Methods This Australian qualitative study involved semi-structured interviews with general practitioners (n =9), practice nurses (n =8), and a community liaison worker employed in general practice (n =1), to explore barriers and facilitators to identifying and managing supportive care for cancer survivors. Data were thematically analysed to develop recurring themes related to the identification and provision of supportive care. Results Four major themes were developed: identification of supportive care needs, time and provision of supportive care, challenges in supportive care for diverse populations, and desire for more information. Improved education; enhanced communication across all levels of healthcare, including centralised access to patient information; and greater knowledge of available services were highlighted as facilitators to the management of supportive care for cancer survivors. Conclusions Targeted efforts to support the facilitators identified here can contribute to more effective management of supportive care for diverse cancer survivor populations to improve the overall quality of care and health outcomes for these individuals.

Care transitions by older adults discharged from hospital require good coordination and communication to prevent adverse events and potentially preventable readmissions. Implementation of multicomponent interventions tailored to patient risk can improve the quality of transitions and reduce potentially preventable readmissions. Several such multicomponent interventions exist, but evidence of their transferability and effectiveness for individuals discharged to residential aged care (RAC) and within the Australian context is required. The Optimising older People’s Transition from acute care Into residential aged care through Multidisciplinary Assessment and Liaison (OPTIMAL) trial is a multi-site hybrid type II stepped wedge cluster randomised controlled trial with embedded process and economic evaluations. The study aims to collaboratively implement a bundle of evidence-based interventions with clinicians, administrators, and researchers to provide systematic support for first time discharges to RAC, and to determine the clinical effectiveness, cost effectiveness, and feasibility, acceptability, adoption and fidelity of implementation. The study design is informed by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, which will guide implementation and process evaluation. The OPTIMAL intervention will be implemented sequentially over 14 months across selected hospital wards in three local health networks (LHNs) in South Australia. Implementation will occur in a random order, with one LHN transitioning to the intervention phase every four months. It will include all patients 65 years and older discharged from the selected wards to RAC for the first time. Eligible participants will be stratified based on their risk of readmission and receive a customized bundle of interventions relative to their level of risk. Each LHN team will tailor an intervention bundle informed by existing evidence and a registered nurse will facilitate its implementation. The primary outcome is the proportion of participants with emergency department presentations and/or readmissions and/or death within 30 and 90 days of discharge. A total of 1545 participants are expected to be enrolled, commencing 1st September 2024. This study will provide evidence on the transferability and effectiveness of implementing multicomponent and risk stratified enhanced care bundles in the Australian context, and can inform improvement activities for care transitions by older adults. Australia New Zealand Clinical Trial Registry ACTRN12624001008516, registered 20th August 2024.

Out-of-pocket health expenditure (OOPHE) significantly impacts people with chronic and complex diseases (CCDs) and injuries. Aboriginal communities experience a higher burden of CCDs and injury, along with greater OOPHE inequities. This project aims to develop and implement a social prescribing digital platform (Web App) to reduce OOPHE. It is grounded in citizen science approaches that value the lived experience and knowledge of Aboriginal people in shaping solutions. The project uses a citizen science methodology adapted for these communities, using knowledge interface methodology to weave together Indigenous and Western knowledges. Research methods (Indigenous, quantitative, qualitative) explore the relational nature of OOPHE risks and protective factors through co-design and workshops with Aboriginal participants to develop the Web App. A community-centric developmental evaluation guides the trial and refinement of the platform, allowing for ongoing learning and adaptation. Process measures inform a national scale-up and evaluation framework. Addressing OOPHE is essential to improving health and wellbeing for Aboriginal and Torres Strait Islander individuals and families living with or at risk of CCDs. This initiative aims to reduce the impact of OOPHE through digital social prescribing, there by connecting people with essential community services to access healthcare, offering a scalable approach to addressing health inequities nationwide.