Economic evaluation: what does a nurse manager need to know?

This paper considers how health economists can assist nurse managers, using the concepts and tools of economic evaluation. We aim to clarify these and also explode some of the myths about economic evaluation and its role in health care decision-making. Economic evaluation techniques compare alternative courses of action in terms of their costs and consequences. There are four principal methods; cost-minimization, cost-effectiveness, cost-utility and cost-benefit analysis, all of which synthesize costs and outcomes, at different levels of outcome. Economic evaluation is an intrinsic part of national decision-making about the efficient provision of effective treatments and services, and increasingly, organizational matters. In the UK, such technology evaluation is disseminated in guidelines from the National Institute for Clinical Effectiveness (NICE), having a top-down impact on the nurse manager. But economic evaluation is increasingly relevant to the nurse manager at local level, through newer techniques such as Programme Budgeting Marginal Analysis (PBMA), which facilitates explicit, transparent decisions, from the bottom-up. Nurse managers need to weigh up competing demands on resources and decide in ways which maximize health gain. Economic evaluation can help here because it presents evidence to challenge or support existing allocations, and provides a systematic framework to analyse health care decisions. In the current context of competition for scarce resources, we suggest that nurse managers need to embrace these techniques, or be marginalized from the resource allocation process

Economic Evaluation of Palliative Care in Ireland

This report examines the cost of providing palliative care in Ireland for individuals facing life-threatening illnesses, outcomes for patients and families resulting from that care, and the patterns and variations among the measures studied. Focusing their examination on three regional areas, researchers found:Wide variations in the availability of palliative care services across the regions.Significant differences in how those services are resourced and models of care.Despite the variation in availability and models of care, costs remain broadly the same across regions.Among the conclusions from examination of key outcomes for the patients:High patient satisfaction with palliative care services across all regions.Where available, hospice care is easier to access and rated more highly on every quality measure than in-hospital care.The ability to access in-hospice services in the last three months of life would be preferable for patients and may provide savings within hospitals

Evidence on the Cost and Cost-effectiveness of Palliative Care: A Literature Review

In the context of limited resources, evidence on costs and cost-effectiveness of alternative methods of delivering health-care services is increasingly important to facilitate appropriate resource allocation. Palliative care services have been expanding worldwide with the aim of improving the experience of patients with terminal illness at the end of life through better symptom control, coordination of care and improved communication between professionals and the patient and family.The aim of this paper is to present results from a comprehensive literature review of available international evidence on the costs and cost-effectiveness of palliative care interventions in any setting (e.g. hospital-based, home-based and hospice care) over the period 2002 -- 2011. Key bibliographic and review databases were searched and the quality of retrieved papers was assessed against a set of 31 indicators developed for this review.A total of 46 papers met the criteria for inclusion in the review, examining the cost and/or utilisation implications of a palliative care intervention with some form of comparator. The main focus of these studies was on direct costs with little focus on informal care or out-of-pocket costs. The overall quality of the studies is mixed, although a number of cohort studies do undertake multivariate regression analysis.Despite wide variation in study type, characteristic and study quality, there are consistent patterns in the results. Palliative care is most frequently found to be less costly relative to comparator groups, and in most cases, the difference in cost is statistically significant

Formal home care utilisation by older adults in Ireland: Evidence from the Irish longitudinal study on ageing

The aim of this study is to provide a population based estimate of the utilisation of publicly financed formal home care by older adults in Ireland and to identify the principal characteristics of those utilising formal home care. Data were collected through computer-aided personal interviews from a representative sample of community living older adults in Ireland. The interviews were conducted between 2009 and 2011 as part of the first wave of the Irish Longitudinal Study on Ageing (TILDA). The study is cross-sectional in design and limited to participants aged 65 years and older (n=3507). Results reveal that 8.2% (95% CI 7.1%-9.3%) of participants utilised publicly financed formal home care in the form of home help and/or personal care. Key determinants of formal home care utilisation were Instrumental Activity of Daily Living (IADL) difficulty (Adj OR 3.8, 95% CI 2.7-5.3), older age (Adj OR 3.4, 95% CI 2.4-4.8) and living alone (Adj OR 2.6, 95% CI 1.9-3.8). Almost half of those utilising formal care did not self-report an Activity of Daily Living (ADL) difficulty or an Instrumental Activity of Daily Living (IADL) difficulty. Government policy aims to reduce the need for long-term residential care by providing formal home care for older adults with low to moderate levels of dependency. This requires an increasing emphasis on personal care provision in the home. No evidence was found in this study to suggest that a shift in emphasis from formal domestic to personal care is taking place in Ireland. The absence of standardised assessment and eligibility criteria are deemed to be barriers to reorientation of the system. From a health services perspective the current situation is not sustainable into the future and requires a focused policy response

Entre la colère… et la rupture du lien social : Des personnes ayant des incapacités témoignent de leur expérience face aux carences de la protection sociale

L’article présente les résultats d’une recherche qualitative qui avait pour objectif d’identifier et de décrire les conséquences sociales sur la santé de l’inaccessibilité aux services et aux compensations financières pour les personnes ayant des incapacités et leurs proches. Cinquante-deux personnes ont été rencontrées lors d’une entrevue individuelle. L’analyse de contenu des entrevues révèle que l’inaccessibilité entraîne des conséquences négatives sur la santé physique, la santé mentale et la participation sociale. L’analyse fait également ressortir comment les personnes composent face aux carences de la protection sociale. Ces résultats sont discutés à la lumière des transformations récentes dans les pratiques de compensation au Québec.This article presents the results of a qualitative study aiming to identify and describe the social and health consequences of the inaccessibility of services and financial compensations for people with disabilities and their close relations. Fifty-two people were individually interviewed. Content analysis of the interviews reveals that inaccessibility leads to negative consequences on physical health, mental health and social participation. The analysis also revealed how people deal with inadequacies in social protection. These results are discussed in light of recent transformations in Quebec’s compensation practices

Applying a typology of health worker migration to non-EU migrant doctors in Ireland

Abstract Background: Research on health worker migration in the Irish context has categorized migrant health workers by country or region of training (for example, non-EU nurses or doctors) or recruitment mechanism (for example, actively recruited nurses). This paper applies a new typology of health worker migrants – livelihood, career-oriented, backpacker, commuter, undocumented and returner migrants (European Observatory on Health Systems and Policies and WHO, vol. 2:129-152, 2014) – to the experiences of non-EU migrant doctors in Ireland and tests its utility for understanding health worker migration internationally. Methods: The paper draws on quantitative survey (N = 366) and qualitative interview (N = 37) data collected from non-EU migrant doctors in Ireland between 2011 and 2013. Results: Categorizing non-EU migrant doctors in Ireland according to the typology (European Observatory on Health Systems and Policies and WHO, vol. 2:129-152, 2014) offers insight into their differing motivations, particularly on arrival. Findings suggest that the career-oriented migrant is the most common type of doctor among non-EU migrant doctor respondents, accounting for 60 % (N = 220) of quantitative and 54 % (N = 20) of qualitative respondents. The authors propose a modification to the typology via the addition of two additional categories – the family migrant and the safety and security migrant. Conclusions: Employing a typology of health worker migration can facilitate a more comprehensive understanding of the migrant medical workforce, a necessary prerequisite for the development of useful policy tools (European Observatory on Health Systems and Policies and WHO, vol. 2:129-152, 2014). The findings indicate that there is some fluidity between categories, as health worker motivations change over time. This indicates the potential for policy levers to influence migrant health worker decision-making, if they are sufficiently “tuned in” to migrant health worker motivation. Keywords: Doctor migration, Migration typology, Medical workforce planning, Health workforce planning, Health human resources for healt

Costs of dialysis for elderly people in the UK.

BACKGROUND: Growing acceptance rates of elderly patients for dialysis requires a careful planning of renal services expansion. As little is known about the actual resource use in patients 70 years and over, we evaluated the entire range of costs related to treatment, hospitalization, medication and other health and social service use, and assessed the impact of socio-demographic and clinical factors on costs. METHODS: Service use and costs were assessed in a 12-month prospective cohort study of 171 dialysis patients, 70 years of age and over, from four hospital-based renal units in London, UK. RESULTS: Total costs ranged between 14,940 pounds and 58,250 pounds per annum. The average annual cost was 22,740 pounds [95% confidence interval (CI), 21,470-24,020 pounds]. The majority of costs were allocated to dialysis treatment and transport (70%), hospitalizations (12%) and medication (12%). Other health and social services accounted for only 6% of total costs. Dialysis and hospitalization costs were pound 68.4 per day on average. Univariate subgroup analyses showed no significant difference between patients on peritoneal dialysis (64.5 pounds) and haemodialysis (71.5 pounds, P = 0.13). Age 80 years and over and presence of peripheral vascular disease (PVD) were associated with higher daily costs of 73.3 pounds compared with 63.2 pounds in the 70-74 age group (P = 0.033) and 76.9 pounds vs 63.8 pounds in patients without PVD (P = 0.022), respectively. Proximity to death was associated with a nearly pound 40 increase in daily costs (96.8 vs 59.7 pounds; P < 0.001). Multiple linear regression analyses confirmed these findings and showed that age 80 years and over and presence of peripheral and cerebrovascular disease were significant predictors of costs. There was a large but marginally significant difference in costs in patients with cancer. We found no evidence that diabetes was associated with higher dialysis and hospitalization costs. CONCLUSIONS: The costs of providing dialysis for patients 70 years and over are largely shaped by the treatment costs rather than by use of community health and social services. Though age above 80 and co-morbidity are associated with increased resource use, average treatment costs are not higher than estimates for dialysis patients in general. This suggests that there is no case for providing treatment to younger patients and denying it to elderly patients on grounds of cost

PROJECTING THE IMPACT OF DEMOGRAPHIC CHANGE ON THE DEMAND FOR AND DELIVERY OF HEALTH CARE IN IRELAND. RESEARCH SERIES NUMBER 13 OCTOBER 2009

Primary care is often the first point of contact with the health care system for people requiring care. Primary care is often thought synonymous with general practitioners, but actually encompasses a large range of different professionals and services including nurses/midwives; physiotherapists; occupational therapists; dentists; opticians; chiropodists; psychologists and pharmacists. The list is not exhaustive, but still gives an indication of the wide range of services that can be grouped under the general heading of primary care. Nonetheless, GPs do have a core part to play in primary care as well as performing the role of ‘gate keeper’ to other health services such as accident and emergency or outpatient care in hospitals. The balance of treatment and referral between general practice and secondary care is, therefore, a very important issue and it has been argued that the under development of primary care services in Ireland in recent decades has contributed, and indeed, may be the most important reason, for the over-crowding of accident and emergency services and long waiting lists for elective procedures in Irish health care (Layte et al., 2007b; Tussing and Wren, 2006)

Comparing the Job Satisfaction and Intention to Leave of Different Categories of Health Workers in Tanzania, Malawi, and South Africa.

Job satisfaction is an important determinant of health worker motivation, retention, and performance, all of which are critical to improving the functioning of health systems in low- and middle-income countries. A number of small-scale surveys have measured the job satisfaction and intention to leave of individual health worker cadres in different settings, but there are few multi-country and multi-cadre comparative studies. The objective of this study was to compare the job satisfaction and intention to leave of different categories of health workers in Tanzania, Malawi, and South Africa. We undertook a cross-sectional survey of a stratified cluster sample of 2,220 health workers, 564 from Tanzania, 939 from Malawi, and 717 from South Africa. Participants completed a self-administered questionnaire, which included demographic information, a 10-item job satisfaction scale, and one question on intention to leave. Multiple regression was used to identify significant predictors of job satisfaction and intention to leave. There were statistically significant differences in job satisfaction and intention to leave between the three countries. Approximately 52.1% of health workers in South Africa were satisfied with their jobs compared to 71% from Malawi and 82.6% from Tanzania (χ2=140.3, p<0.001). 18.8% of health workers in Tanzania and 26.5% in Malawi indicated that they were actively seeking employment elsewhere, compared to 41.4% in South Africa (χ2=83.5, p<0.001). The country differences were confirmed by multiple regression. The study also confirmed that job satisfaction is statistically related to intention to leave. We have shown differences in the levels of job satisfaction and intention to leave between different groups of health workers from Tanzania, Malawi, and South Africa. Our results caution against generalising about the effectiveness of interventions in different contexts and highlight the need for less standardised and more targeted HRH strategies than has been practised to date