Aims/hypothesis: The aim of this study was to determine the long-term cost-effectiveness and return on investment of implementing a structured lifestyle intervention to reduce excessive gestational weight gain and associated incidence of gestational diabetes mellitus (GDM) and type 2 diabetes mellitus. Methods: A decision-analytic Markov model was used to compare the health and cost-effectiveness outcomes for (1) a structured lifestyle intervention during pregnancy to prevent GDM and subsequent type 2 diabetes; and (2) current usual antenatal care. Life table modelling was used to capture type 2 diabetes morbidity, mortality and quality-adjusted life years over a lifetime horizon for all women giving birth in Australia. Costs incorporated both healthcare and societal perspectives. The intervention effect was derived from published meta-analyses. Deterministic and probabilistic sensitivity analyses were used to capture the impact of uncertainty in the model. Results: The model projected a 10% reduction in the number of women subsequently diagnosed with type 2 diabetes through implementation of the lifestyle intervention compared with current usual care. The total net incremental cost of intervention was approximately AU$70 million, and the cost savings from the reduction in costs of antenatal care for GDM, birth complications and type 2 diabetes management were approximately AU$85 million. The intervention was dominant (cost-saving) compared with usual care from a healthcare perspective, and returned AU$1.22 (95% CI 0.53, 2.13) per dollar invested. The results were robust to sensitivity analysis, and remained cost-saving or highly cost-effective in each of the scenarios explored. Conclusions/interpretation: This study demonstrates significant cost savings from implementation of a structured lifestyle intervention during pregnancy, due to a reduction in adverse health outcomes for women during both the perinatal period and over their lifetime. Graphical

Objective The aim was to project the health and economic outcomes of cardiovascular disease (CVD) among people with type 2 diabetes from Australian public healthcare and societal perspectives over the next decade. Methods A dynamic multistate model with yearly cycles was developed to project cardiovascular events among Australians with type 2 diabetes aged 40–89 years from 2022 to 2031. CVD risk (myocardial infarction [MI] and stroke) in the type 2 diabetes population was estimated using the 2013 pooled cohort equation, and recurrent cardiovascular event rates in the type 2 diabetes with established CVD population were obtained from the global Reduction of Atherothrombosis for Continued Health (REACH) registry. Costs and utilities were derived from published sources. Outcomes included fatal and non-fatal MI and stroke, years of life lived, quality-adjusted life years (QALYs), total healthcare costs, and total productivity losses. The annual discount rate was 5%, applied to outcomes and costs. Results Between 2022 and 2031, a total of 83,618 non-fatal MIs (95% uncertainty interval [UI] 83,170–84,053) and 58,774 non-fatal strokes (95% UI 58,458–59,013) were projected. Total years of life lived and QALYs (discounted) were projected to be 9,549,487 (95% UI 9,416,423–9,654,043) and 6,632,897 (95% UI 5,065,606–7,591,679), respectively. Total healthcare costs and total lost productivity costs (discounted) were projected to be 9.59 billion Australian dollars (AU$) (95% UI 1.90–30.45 billion) and AU$9.07 billion (95% UI 663.53 million–33.19 billion), respectively. Conclusions CVD in people with type 2 diabetes will substantially impact the Australian healthcare system and society over the next decade. Future work to investigate different strategies to optimize the control of risk factors for the prevention and treatment of CVD in type 2 diabetes in Australia is warranted.

Background Objective This study aimed to systematically synthesise the cost-effectiveness of screening strategies to detect heterozygous familial hypercholesterolemia (FH). Methods We searched seven databases from inception to 2 February , 2023, for eligible cost-effective analysis (CEA) that evaluated screening strategies for FH versus the standard care for FH detection. Independent reviewers performed the screening, data extraction and quality evaluation. Cost results were adapted to 2022 US dollars (US$) to facilitate comparisons between studies using the same screening strategies. Cost-effectiveness thresholds were based on the original study criteria. Results A total of 21 studies evaluating 62 strategies were included in this review, most of the studies (95%) adopted a healthcare perspective in the base case, and majority were set in high-income countries. Strategies analysed included cascade screening (23 strategies), opportunistic screening (13 strategies), systematic screening (11 strategies) and population-wide screening (15 strategies). Most of the strategies relied on genetic diagnosis for case ascertainment. The most common comparator was no screening, but some studies compared the proposed strategy versus current screening strategies or versus the best next alternative. Six studies evaluated screening in children while the remaining were targeted at adults. From a healthcare perspective, cascade screening was cost-effective in 78% of the studies [cost-adapted incremental cost-effectiveness ratios (ICERs) ranged from dominant to 2022 US$ 104,877], opportunistic screening in 85% (ICERs from US$4959 to US$41,705), systematic screening in 80% (ICERs from US$2763 to US$69,969) and population-wide screening in 60% (ICERs from US$1484 to US$223,240). The most common driver of ICER identified in the sensitivity analysis was the long-term cost of lipid-lowering treatment. Conclusions Based on reported willingness to pay thresholds for each setting, most CEA studies concluded that screening for FH compared with no screening was cost-effective, regardless of the screening strategy. Cascade screening resulted in the largest health benefits per person tested.

Aim: To determine whether patients presenting to the emergency department (ED) with possible benign paroxysmal positional vertigo (BPPV) are managed in accordance with best practice guidelines, and whether physiotherapists are involved in their care. Design: Retrospective observational study. Participants: Ninety-six consecutive patients presenting to one of three EDs with vertigo, dizziness or imbalance symptoms documented at triage. Individuals with a clear non-vestibular cause of symptoms were excluded. Outcome Measures: Proportional adherence to clinical practice guidelines by medical and physiotherapy clinicians, primary diagnosis, incidence of falls, admission to hospital, and referral to a physiotherapy service. Results: Adherence to clinical practice guidelines by both professions was low, with only 25 (26%, 95% CI: 18–36%) and 3 (14%, 95% CI: 4–36%) patients assessed by a medical clinician or physiotherapist, respectively, receiving the gold-standard Dix–Hallpike test. Sixty-four (67%) individuals were given a diagnosis of undifferentiated dizziness. Of the 26 (27%) patients with a primary BPPV diagnosis, only three (12%) were treated with a canalith-repositioning technique, and four (15%) reviewed by a physiotherapist. Conclusion: Adherence to best-practice guidelines for the management of BPPV in individuals presenting to the ED is low, and physiotherapists are seldom involved in their management.

Globally, around half of pregnancies are affected by excess gestational weight gain, which is strongly and independently associated with adverse maternal and infant outcomes.^1,2 These outcomes include development of gestational diabetes and hypertensive disease in pregnancy (HDP), together with increased risk of cesarean delivery and/or neonatal intensive care.^1,3-5 In 2019, 48% of pregnant women in Australia were classified as overweight or obese, 11% were diagnosed with gestational diabetes, and 3% with HDP.⁶ Health service costs associated with pregnancy and birth in Australia were 25% higher for women with HDP, and 13% for gestational diabetes, compared with those without these conditions.^7,8