Use of Adjuvanted Quadrivalent Influenza Vaccine in Older-Age Adults: A Systematic Review of Economic Evidence.

Influenza vaccination is an important public health measure that can reduce disease burden, especially among older persons (those aged 65 and over) who have weaker immune systems. Evidence suggests enhanced vaccines, including adjuvanted quadrivalent vaccines (aQIV), may be particularly effective in this group. This study reports the results of a systematic review of the cost-effectiveness of aQIV in this population. The review was undertaken and reported in accordance with good practice guidelines. Medline and EMBASE were searched from 2013 to the present. Pre-selected eligibility criteria were employed and quality assessment undertaken using the Consensus Health Economic Criteria (CHEC-extended) checklist and Consolidated Health Economic Evaluation Reporting Standard (CHEERS) 2022 checklists. A total of 124 records were returned, with 10 full text papers retained. All were modelling studies and exhibited heterogeneity in approach, perspective, and parameter estimation. Nine papers reported cost-effectiveness ranging from EUR 6694/QALY to EUR 20,000/QALY in evaluations employing a payer perspective and from EUR 3936/QALY to EUR 17,200/QALY in those using a societal perspective. Results remained robust to a range of sensitivity analyses. One paper that reported contrary findings adopted a distinct modelling approach. It is reasonable to conclude that there is a broad consensus as to the cost-effectiveness of aQIV in this population group.

A cost-effectiveness analysis of a universal, preventative-focused, parent and infant programme.

BACKGROUND: This study assessed whether a relatively newly developed Parent and Infant (PIN) parenting support programme was cost-effective when compared to services as usual (SAU). METHODS: The cost-effectiveness of the PIN programme versus SAU was assessed from an Irish health and social care perspective over a 24-month timeframe and within the context of a non-randomised, controlled before-and-after trial. In total, 163 parent-infant dyads were included in the study (86 intervention, 77 control). The primary outcome measure for the economic evaluation was the Parenting Sense of Competence Scale (PSOC). RESULTS: The average cost of the PIN programme was €647 per dyad. The mean (SE) cost (including programme costs) was €7,027 (SE €1,345) compared to €4,811 (SE €593) in the control arm, generating a (non-significant) mean cost difference of €2,216 (bootstrap 95% CI -€665 to €5,096; p = 0.14). The mean incremental cost-effectiveness of the PIN service was €614 per PSOC unit gained (bootstrap 95% CI €54 to €1,481). The probability that the PIN programme was cost-effective, was 87% at a willingness-to-pay of €1,000 per one unit change in the PSOC. CONCLUSIONS: Our findings suggest that the PIN programme was cost-effective at a relatively low willingness-to-pay threshold when compared to SAU. This study addresses a significant knowledge gap in the field of early intervention by providing important real world evidence on the implementation costs and cost-effectiveness of a universal early years parenting programme. The challenges involved in assessing the cost-effectiveness of preventative interventions for very young children and their parents are also discussed. TRIAL REGISTRATION: ISRCTN17488830 (Date of registration: 27/11/15). This trial was retrospectively registered.

Melanoma-related costs by disease stage and phase of management in Ireland.

BACKGROUND: Management options for the treatment of melanoma have expanded in recent years. In an era of promising, but expensive novel pharmacological treatments, robust stage-specific melanoma-related cost estimates are necessary to support budgetary planning, evaluation of cost-effectiveness and to contribute to the investment case for prevention. METHODS: A detailed decision model, describing the melanoma care pathway (by disease stage) from diagnosis, through treatment and follow-up was developed over a 5-year time frame from the perspective of the Irish healthcare system. The model was populated with real-world data from the National Cancer Registry Ireland. Uncertainty was explored using one-way and probabilistic sensitivity analysis. RESULTS: The cost of managing a case of melanoma diagnosed at Stage IV (€122 985) was more than 25 times more expensive than managing a case diagnosed at Stage IA (€4269). Total costs were sensitive to the choice of immunotherapeutic and targeted drug, duration of treatment and proportion of patients receiving immunotherapy agents. CONCLUSIONS: The rising incidence of melanoma and high cost of new novel therapies presents an immediate challenge to cancer control and public health globally. This study highlights the cost differential between early and late detection and the potential return on investment for prevention versus high-cost treatment.

An umbrella review of the effectiveness of fiscal and pricing policies on food and non-alcoholic beverages to improve health.

Poor quality diets represent major risk factors for the global burden of disease. Modeling studies indicate a potential for diet-related fiscal and pricing policies (FPs) to improve health. There is real-world evidence (RWE) that such policies can change behavior; however, the evidence regarding health is less clear. We conducted an umbrella review of the effectiveness of FPs on food and non-alcoholic beverages in influencing health or intermediate outcomes like consumption. We considered FPs applied to an entire population within a jurisdiction and included four systematic reviews in our final sample. Quality appraisal, an examination of excluded reviews, and a literature review of recent primary studies assessed the robustness of our results. Taxes and, to some extent, subsidies are effective in changing consumption of taxed/subsidized items; however, substitution is likely to occur. There is a lack of RWE supporting the effectiveness of FPs in improving health but this does not mean that they are ineffective. FPs may be important for improving health but their design is critical. Poorly designed FPs may fail to improve health and could reduce support for such policies or be used to support their repeal. More high-quality RWE on the impact of FPs on health is needed.

An umbrella review of the acceptability of fiscal and pricing policies to reduce diet-related noncommunicable disease.

CONTEXT: Poor diet has been implicated in a range of noncommunicable diseases. Fiscal and pricing policies (FPs) may offer a means by which consumption of food and non-alcoholic beverages with links to such diseases can be influenced to improve public health. OBJECTIVE: To examine the acceptability of FPs to reduce diet-related noncommunicable disease, based on systematic review evidence. DATA SOURCES: MEDLINE, EMBASE, PsychInfo, SCI, SSCI, Web of Science, Scopus, EconLit, the Cochrane Library, Epistemonikos, and the Campbell Collaboration Library were searched for relevant studies published between January 1, 1990 and June 2021. DATA EXTRACTION: The studies included systematic reviews of diet-related FPs and: used real-world evidence; examined real or perceived barriers/facilitators; targeted the price of food or non-alcoholic beverages; and applied to entire populations within a jurisdiction. A total of 9996 unique relevant records were identified, which were augmented by a search of bibliographies and recommendations from an external expert advisory panel. Following screening, 4 systematic reviews remained. DATA ANALYSIS: Quality appraisal was conducted using the AMSTAR 2 tool. A narrative synthesis was undertaken, with outcomes grouped according to the WHO-INTEGRATE criteria. The findings indicated a paucity of high-quality systematic review evidence and limited public support for the use of FPs to change dietary habits. This lack of support was related to a number of factors that included: their perceived potential to be regressive; a lack of transparency, ie, there was mistrust around the use of revenues raised; a paucity of evidence around health benefits; the deliberate choice of rates that were lower than those considered necessary to affect diet; and concerns about the potential of such FPs to harm economic outcomes such as employment. CONCLUSION: The findings underscore the need for high-quality systematic review evidence on this topic, and the importance of responding to public concerns and putting in place mechanisms to address these when implementing FPs. This study was funded by Safefood [02A-2020]. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42021274454.

Mesenchymal stromal cell therapy compared to SGLT2-inhibitors and usual care in treating diabetic kidney disease: A cost-effectiveness analysis.

BACKGROUND AND OBJECTIVES: To simulate the cost-effectiveness of Mesenchymal Stromal Cell (MSC) therapy compared to sodium/glucose co-transporter 2 inhibitors (SGLT2i) or usual care (UC) in treating patients with Diabetic Kidney Disease (DKD). DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: This Markov-chain Monte Carlo model adopted a societal perspective and simulated 10,000 patients with DKD eligible for MSC therapy alongside UC using a lifetime horizon. This cohort was compared with an SGLT2i alongside UC arm and a UC only arm. Model input data were extracted from the literature. A threshold of $47,000 per quality-adjusted life year and a discount rate of 3% were used. The primary outcome measure was incremental net monetary benefit (INMB). Sensitivity analysis was conducted to examine: parameter uncertainty; threshold effects regarding MSC effectiveness and cost; and INMB according to patient age (71 vs 40 years), sex, and jurisdiction (UK, Italy and Ireland). RESULTS: While MSC was more cost-effective than UC, both the UC and MSC arms were dominated by SLGT2i. Relative to SGLT2i, the INMB's for MSC and UC were -$4,158 and -$10,085 respectively indicating that SGLT2i, MSC and UC had a 64%, 34% and 1% probability of being cost-effective at the given threshold, respectively. This pattern was consistent across most scenarios; driven by the relatively low cost of SGLT2i and demonstrated class-effect in delaying kidney failure and all-cause mortality. When examining younger patients at baseline, SGLT2i was still the most cost-effective but MSC performed better against UC given the increased lifetime benefit from delaying progression to ESRD. CONCLUSIONS: The evidence base regarding the effectiveness of MSC therapy continues to evolve. The potential for these therapies to reverse kidney damage would see large improvements in their cost-effectiveness as would targeting such therapies at younger patients and/or those for whom SGLT2i is contra-indicated.

Hospital Costs and Fatality Rates of Traumatic Assaults by Mechanism in the US, 2016-2018.

Importance: Estimates of the total economic cost of firearm violence are important in drawing attention to this public health issue; however, studies that consider violence more broadly are needed to further the understanding of the extent to which such costs can be avoided. Objectives: To estimate the association of firearm assaults with US hospital costs and deaths compared with other assault types. Design, Setting, and Participants: The 2016-2018 US Nationwide Emergency Department Sample and National Inpatient Sample, Healthcare Cost and Utilization Project were used in this cross-sectional study of emergency department (ED) and inpatient admissions for assaults involving a firearm, sharp object, blunt object, or bodily force identified using International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes. Differences in ED and inpatient costs (2020 US dollars) across mechanisms were estimated using ordinary least-squares regression with and without adjustments for year and hospital, patient, and injury characteristics. The Centers for Disease Control and Prevention underlying cause of death data were used to estimate national death rates and hospital case-fatality rates across mechanisms. Cost analysis used a weighted sample. National death rates and hospital case-fatality rates used US resident death certificates, covering 976 million person-years. Hospital case-fatality rates also used nationally weighted ED records covering 2.7 million admissions. Data analysis was conducted from March 1, 2021, to March 31, 2022. Exposure: The primary exposure was the mechanism used in the assault. Main Outcomes and Measures: Emergency department and inpatient costs per record. National death rates and hospital case-fatality rates. Results: Overall, 2.4 million ED visits and 184 040 inpatient admissions for assault were included. Across all mechanisms, the mean age of the population was 32.7 (95% CI, 32.6-32.9) years in the ED and 36.4 (95% CI, 36.2-36.7) years in the inpatient setting; 41.9% (95% CI, 41.2%-42.5%) were female in the ED, and 19.1% (95% CI, 18.6%-19.6%) of inpatients were female. Most assaults recorded in the ED involved publicly insured or uninsured patients and hospitals in the Southern US. Emergency department costs were $678 (95% CI, $657-$699) for bodily force, $861 (95% CI, $813-$910) for blunt object, $996 (95% CI, $925-$1067) for sharp object, and $1388 (95% CI, $1254-$1522) for firearm assaults. Corresponding inpatient costs were $14 702 (95% CI, $14 178-$15 227) for bodily force, $17 906 (95% CI, $16 888-$18 923) for blunt object, $19 265 (95% CI, $18 475-$20 055) for sharp object, and $34 949 (95% CI, $33 654-$36 244) for firearm assaults. National death rates per 100 000 were 0.04 (95% CI, 0.03-0.04) for bodily force, 0.03 (95% CI, 0.03-0.03) for blunt object, 0.54 (95% CI, 0.52-0.55) for sharp object, and 4.40 (95% CI, 4.36-4.44) for firearm assaults. Hospital case fatality rates were 0.01% (95% CI, 0.009%-0.012%) for bodily force, 0.05% (95% CI, 0.04%-0.06%) for blunt object, 1.05% (95% CI, 1.00%-1.09%) for sharp object, and 15.26% (95% CI, 15.04%-15.49%) for firearm assaults. In regression analysis, ED costs for firearm assaults were 59% to 99% higher than costs for nonfirearm assaults, and inpatient costs were 67% to 118% higher. Conclusions and Relevance: The findings of this study suggest that it may be useful for policies aimed at reducing the costs of firearm violence to consider violence more broadly to understand the extent to which costs can be avoided.

A Review to Populate A Proposed Cost-Effectiveness Analysis of Glaucoma Screening in Sub-Saharan Africa.

To populate a proposed cost-effectiveness analysis of glaucoma screening in Sub-Saharan Africa (SSA).A complete search was conducted on PubMed, Medline and African Journals Online (AJOL) to obtain relevant published articles, which were included in this review. All relevant articles on prevalence of glaucoma in SSA and among other African-derived populations, severity of glaucoma, cost of diagnosis and management, clinical effectiveness of glaucoma screening and treatment and the different glaucoma screening strategies in SSA were reviewed.Population screening interventions for glaucoma may be considered as follows: standalone screening for glaucoma, screening for glaucoma during cataract outreach, and screening incorporated with diabetic retinopathy image review using tele-ophthalmology. Our review suggests that cost of glaucoma treatment is relatively low with cost of medical treatment ranging from USD 273 to USD 480 per year/patient and surgical treatment cost of USD 283 per patient as with other developing countries. Compliance with medication is moderate to good in about 50% of glaucoma patients. Prevalence of glaucoma is much higher in SSA and almost 50% of glaucoma patients are blind in at least one eye at presentation in clinics (without outreach screening). Our review suggests a moderate sensitivity and specificity in identifying glaucoma with basic equipment (direct ophthalmoscope, contact tonometer and frequency doubling technology) during outreach screening although about a third or fewer take up glaucoma services in clinics.Our review provides the necessary information to conduct a cost-effective analysis of glaucoma screening in SSA using the decision Markov model.

Does the use of patient decision aids lead to cost savings? a systematic review.

OBJECTIVES: To update a previous systematic review to determine if patient decision aid (PDA) interventions generate savings in healthcare settings, and if so, from which perspective (ie, patient, organisation providing care, society). DESIGN: Systematic review. DATA SOURCES: MEDLINE, CINAHL, PsycINFO, Web of Science, Cochrane Library, Embase, Campbell Collaboration Library, EconLit, Business Source Complete, Centre for Reviews and Dissemination: NHS Economic Evaluations Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) from 15 March 2013 to 25 January 2019. The references of studies that met the eligibility criteria and any publications related to conference abstracts or registered clinical trials were reviewed to increase the sensitivity of the search. ELIGIBILITY CRITERIA: Full and partial economic evaluations with an experimental, quasi-experimental or randomised controlled design were included. The intervention had to satisfy the pre-determined minimum conditions necessary to be defined as a PDA, and (for full evaluations) provide details on the comparator used. DATA EXTRACTION AND SYNTHESIS: All study outcomes and economic data were extracted. The reporting and quality of the economic analyses were independently assessed by two health economists. RESULTS: Of 5066 studies, 22 studies were included, including the 8 studies from the previous review. Twelve studies reported cost-savings (range=US$10 to US$81 156; US dollars in 2020), primarily from the organisational or health system perspective, and 10 studies did not. However, due to the quality of the economic analyses, and the related issues with the interpretative validity of results it would be inappropriate to say that PDAs will generate savings, from any perspective. CONCLUSIONS: It is unclear whether PDAs will generate savings. Greater consensus on what constitutes a PDA and the need to compare them against usual care over a sufficient time horizon to allow valid assessment of costs and outcomes is required. PROSPERO REGISTRATION NUMBER: CRD42019118457.

Hearing loss, mental well-being and healthcare use: results from the Health Survey for England (HSE).

BACKGROUND: Hearing loss (HL) affects an estimated 17% of adults in Britain, 19% in Canada and 16% in the USA. Evidence points to the impact of HL on aspects of physical and mental health as well as autonomy, cognition, memory and social isolation. This suggests the relationship between HL and service use may arise indirectly as well as directly, an issue that warrants investigation. METHODS: We used data from Health Survey for England (2014) on objectively and subjectively measured HL, mental and physical health as well as aspects of well-being related to autonomy, cognition, memory and social isolation within a series of bivariate probit models to examine the relationship between health and GP use in the past two weeks. Data for between ~3000 and 1700 individuals were examined. RESULTS: A significant correlation in errors was found in each aspect of well-being demonstrating the appropriateness of the bivariate model. In three of the six regressions (concentration, memory and GHQ score) wearing a hearing aid (in some age groups) attenuated the impact of HL on outcome (relative to being younger or not wearing a hearing aid). CONCLUSIONS: While HL did not directly predict use of GP services, it consistently predicted aspects of cognition, autonomy, mobility and memory found to predict service use.

Preferences for a third-trimester ultrasound scan in a low-risk obstetric population: a discrete choice experiment.

OBJECTIVE: Establish maternal preferences for a third-trimester ultrasound scan in a healthy, low-risk pregnant population. DESIGN: Cross-sectional study incorporating a discrete choice experiment. SETTING: A large, urban maternity hospital in Northern Ireland. PARTICIPANTS: One hundred and forty-six women in their second trimester of pregnancy. METHODS: A discrete choice experiment was designed to elicit preferences for four attributes of a third-trimester ultrasound scan: health-care professional conducting the scan, detection rate for abnormal foetal growth, provision of non-medical information, cost. Additional data collected included age, marital status, socio-economic status, obstetric history, pregnancy-specific stress levels, perceived health and whether pregnancy was planned. Analysis was undertaken using a mixed logit model with interaction effects. MAIN OUTCOME MEASURES: Women's preferences for, and trade-offs between, the attributes of a hypothetical scan and indirect willingness-to-pay estimates. RESULTS: Women had significant positive preference for higher rate of detection, lower cost and provision of non-medical information, with no significant value placed on scan operator. Interaction effects revealed subgroups that valued the scan most: women experiencing their first pregnancy, women reporting higher levels of stress, an adverse obstetric history and older women. CONCLUSIONS: Women were able to trade on aspects of care and place relative importance on clinical, non-clinical outcomes and processes of service delivery, thus highlighting the potential of using health utilities in the development of services from a clinical, economic and social perspective. Specifically, maternal preferences exhibited provide valuable information for designing a randomized trial of effectiveness and insight for clinical and policy decision makers to inform woman-centred care.

Public perceptions of coronary events risk factors: a discrete choice experiment.

OBJECTIVES: To assess public perceptions of coronary heart disease (CHD) risk factors. DESIGN: Discrete choice experiment questionnaire. SETTING: Six provincial centres in Northern Ireland. PARTICIPANTS: 1000 adults of the general public in Northern Ireland. PRIMARY AND SECONDARY OUTCOMES: The general public's perception of CHD risk factors. The effect of having risk factor(s) on that perception. RESULTS: Two multinomial logit models were created. One was a basic model (no heterogeneity permitted), while the other permitted heterogeneity based on respondents' characteristics. In both models individuals with very high cholesterol were perceived to be at the highest risk of having a coronary event. Respondents who reported having high cholesterol perceived the risk contribution of very high cholesterol to be greater than those who reported having normal cholesterol. Similar findings were observed with blood pressure and smoking. Respondents who were male and older perceived the contribution of age and gender to be lower than respondents who were female and younger. CONCLUSIONS: Respondents with different risk factors perceived such factors differently. These divergent perceptions of CHD risk factors could be a barrier to behavioural change. This brings into focus the need for more tailored health promotion campaigns to tackle CHD.

Cost-utility analysis of a pharmacy-led self-management programme for patients with COPD.

OBJECTIVE: To undertake a cost-utility analysis (CUA) of a pharmacy-led self-management programme for Chronic Obstructive Pulmonary Disease (COPD). SETTING: A single outpatient COPD clinic at the Mater Hospital, Belfast, Northern Ireland between. METHOD: CUA alongside a randomised control trial. The economic analysis used data from 127 COPD patients aged over 45 years, with an FEV1 of 30-80% of the predicted normal value. Participants received either a pharmacy-led education and self-management programme, or usual care. One year costs were estimated from the perspective of the National Health Service and Personal Social Services and quality-adjusted life years (QALYs) were calculated based on responses to the EQ-5D at baseline, 6 and 12 months. MAIN OUTCOME MEASURE: Cost per QALY gained. RESULTS: The mean differences in costs and effects between the self-management and education programme and usual care were -£671.59 (95 CI%: -£1,584.73 to -£68.14) and 0.065 (95% CI; 0.000-0.128). Thus the intervention was the dominant strategy as it was both less costly and more effective than usual care. The probability of the intervention being cost-effective was 95% at a threshold of £20,000/QALY gained. Sensitivity analyses indicated that conclusions were robust to variations in most of the key parameters. CONCLUSION: The self-management and education programme was found to be highly cost-effective compared to usual care. Further research is required to establish what aspects of self-management and education programmes have the greatest impact on cost-effectiveness.

'We're just not getting it right'--how should we provide care to the older person with multi-morbid chronic conditions?

AIMS AND OBJECTIVES: The aim was to review available literature on research and service evaluation evidence of nurse-led case management services targeting older people with multiple chronic conditions in their own homes. This was anticipated to highlight important issues for nursing practice, healthcare policy, service provision and health service research. BACKGROUND: Enhanced roles for nurses have developed in response to demands for increased efficiency in the provision of healthcare especially in the area of chronic disease management. It is apparent that the evidence to support nurses providing a case management approach for patients with multimorbid chronic conditions in their home environment is ambiguous. DESIGN: A systematic review of the literature. METHODS: The review was carried out across multiple sources including search and alert engines, electronic databases, relevant journal websites and grey literature. The inclusion criteria applied concentrated on articles in the English language, case management intervention involving nurses providing care in the patients' own home and older people (aged over 65 years) with multiple chronic illnesses. Of a total of 568 papers identified, eight were of relevance and included in the review. RESULTS: The qualitative data derived from this systematic review suggests that access to case management services had a positive impact on the patient, the carer and the healthcare staff particularly the General Practitioner. In contrast the more robust quantitative data does not demonstrate a significant impact on emergency admissions, bed days, nor costs. CONCLUSIONS: Further research is needed to understand how case management can most effectively improve service effectiveness for patients and their carers and reduce cost of care. RELEVANCE TO CLINICAL PRACTICE: A new emphasis on comparative effectiveness research is required which has the potential to reshape the whole system of healthcare provision for patients with complex needs.

A cluster randomized controlled trial of an adapted U.S. model of pharmaceutical care for nursing home residents in Northern Ireland (Fleetwood Northern Ireland study): a cost-effectiveness analysis.

OBJECTIVES: To evaluate the cost-effectiveness of an adapted U.S. model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood NI Study). DESIGN: Economic evaluation alongside a cluster randomized controlled trial. SETTING: Nursing homes in NI randomized to intervention (receipt of the adapted model of care; n=11) or control (usual care continued; n=11). PARTICIPANTS: Residents aged 65 and older who provided informed consent (N=253; 128 intervention, 125 control) and who had full resource use data at 12 months. INTERVENTION: Trained pharmacists reviewed intervention home residents' clinical and prescribing information for 12 months, applied an algorithm that guided them in assessing the appropriateness of psychoactive medication, and worked with prescribers (general practitioners) to make changes. The control homes received usual care in which there was no pharmacist intervention. MEASUREMENTS: The proportion of residents prescribed one or more inappropriate psychoactive medications (according to standardized protocols), costs, and a cost-effectiveness acceptability curve. The latter two outcomes are the focus for this article. RESULTS: The proportions of residents receiving inappropriate psychoactive medication at 12 months in the intervention and control group were 19.5% and 50.4%, respectively. The mean cost of healthcare resources used per resident per year was $4,923 (95% confidence interval (CI)=$4,206-5,640) for the intervention group and $5,053 (95% CI=$4,328-5,779) for the control group. The probability of the intervention being cost-effective was high, even at low levels of willingness to pay to avoid a resident receiving inappropriately prescribed psychoactive medication. CONCLUSION: The Fleetwood NI model of care was more cost-effective than usual care.

Coronary heart disease: health knowledge and behaviour.

OBJECTIVE: To determine the current level of knowledge and understanding of CHD in the general public in Northern Ireland and to identify factors that are associated with higher knowledge levels. SETTING: Six provincial centres in Northern Ireland. METHODS: The data in the present study were collected using an interview administered questionnaire. 1,000 members of the general public were interviewed face-to-face. CHD knowledge was computed as a continuous variable, i.e. higher score represents better CHD knowledge. MAIN OUTCOME MEASURE: CHD knowledge in the general public in Northern Ireland. RESULTS: Study respondents displayed limited knowledge and understanding of CHD. Study respondents who achieved higher CHD knowledge scores were more likely to report: exercising for 30 min three times or more per week, paying attention to their diet, being overweight, having a family history of CHD, living in a higher socioeconomic area (according to postcode) and having attended tertiary education. Respondents in the present study while recognising the role that community pharmacists had to play in helping patients manage their prescribed medicines, did not recognise the community pharmacists' role in other aspects of CHD detection or management. CONCLUSION: The deficit in CHD knowledge could translate into inadequate preventative behaviour patterns and suboptimal clinical outcomes. If community pharmacists wish to become increasingly involved in public health delivery relating to CHD they need to develop effective and accessible services and promote these to the public who at present do not recognise this role of the community pharmacist.

Cost description of inpatient treatment for ankle fracture.

BACKGROUND: The study estimated the hospital costs associated with the surgical fixation of ankle fractures by either open reduction internal fixation (ORIF) or external fixation. METHOD: A retrospective review of the clinical records of all 264 patients admitted with an ankle fracture requiring surgical stabilisation between 1 March 2007 and 29 February 2008. Patient records were examined for a minimum of 6 months after primary admission. A mean cost per patient was calculated based on patient-level hospital resource use. This included all procedures received during both their primary hospitalisation and subsequent re-admissions. RESULTS: Approximately equal numbers of males and females (mean age 46.2 years) were admitted, and males were significantly younger than females. The mean length of stay was 10.8 days (SD 9.1); however, ORIF (which was performed in the vast majority of cases, 94.7%) was associated with a much shorter mean length of stay compared with external fixation (10.4 days; SD 8.9 vs. 17.4 days; SD 10.2). The mean total hospital cost per patient including was £4730.28 (SD £2340.73) with a higher mean cost for those who received external fixation as the primary procedure (£9453.92; SD £3391.84) compared with ORIF (£4465.76; SD £1965.10). Patients with severe health problems had significantly higher costs than fit and healthy patients (£5982.65; SD £28 77.74 vs. £4375.00; SD £1957.65). CONCLUSIONS: The results highlight the considerable hospital costs associated with the surgical fixation of an ankle fracture, thus providing valuable information for resource planners. Future research should broaden the perspective of the economic analysis to include rehabilitation costs and assess the cost-effectiveness of potential cost-saving strategies.

Associations between maternal characteristics and pregnancy-related stress among low-risk mothers: an observational cross-sectional study.

BACKGROUND: Pregnancy is viewed as a major life event and, while the majority of healthy, low-risk women adapt well to pregnancy, there are those whose levels of stress are heightened by the experience. OBJECTIVES: To determine the level of pregnancy-related stress experienced by a group of healthy, low-risk pregnant women and to relate the level of stress with a number of maternal characteristics. DESIGN: An observational cross-sectional study. SETTING: A large, urban maternity centre in Northern Ireland. PARTICIPANTS: Of the 306 pregnant women who were invited to participate, 278 provided informed consent and were administered one self-complete questionnaire. Due to the withdrawal criteria, 15 questionnaires were removed from the analysis, resulting in a final sample of 263 healthy, low-risk pregnant women. METHODS: Levels of stress were measured using a self-report measure designed to assess specific worries and concerns relating to pregnancy. Maternal characteristics collected included age, marital status, social status, parity, obstetric history, perceived health status and 'wantedness' for the pregnancy. Regression analysis was undertaken using an ordinary linear regression model. RESULTS: The mean prenatal distress score in the sample was 15.1 (SD=7.4; range 0-46). The regression model showed that women who had had previous pregnancies, with or without complications, had significantly lower mean prenatal distress scores than primiparous women (p<0.01). Women reporting poorer physical health had higher mean prenatal distress scores than those who reported at least average health, while women aged 16-20 experienced a mean increase in the reported prenatal distress score (p<0.05) in comparison to the reference group of 36 years and over. CONCLUSIONS: This study brings to light the prevalence of pregnancy-related stress within a sample representative of healthy, low-risk women. Current antenatal care is ill-equipped to identify women suffering from high levels of stress; yet a growing body of research evidence links stress with adverse pregnancy outcomes. This study emphasises that healthy, low-risk women experience a range of pregnancy-related stress and identification of stress levels, either through the use of a simple stress measurement tool or through the associated factors identified within this research study, provides valuable data on maternal well-being.

Remote diagnosis of congenital heart disease: the impact of telemedicine.

OBJECTIVES: To determine the accuracy of remote diagnosis of congenital heart disease (CHD) by real-time transmission of echocardiographic images via integrated services digital network (ISDN) lines, to assess the impact on patient management and examine cost implications. DESIGN: Prospective comparison of echocardiograms on infants with suspected significant CHD performed as follows: (1) hands-on evaluation and echocardiogram by a paediatrician at a district general hospital (DGH) followed by (2) transmission of the echocardiogram via ISDN 6 with guidance from a paediatric cardiologist and finally (3) hands-on evaluation and echocardiogram by a paediatric cardiologist. The economic analysis compares the cost of patient care associated with the telemedicine service with a hypothetical control group. SETTING: Neonatal units of three DGH and a UK regional paediatric cardiology unit. RESULTS: Echocardiograms were transmitted on 124 infants. In five cases scans were inadequate for diagnosis. Of the remaining 119 tele-echocardiograms, a follow-up echocardiogram was performed on 109/119 (92%). Major CHD was diagnosed in 39/109 infants (36%) and minor CHD in 45 (41%). The tele-echo diagnosis was accurate in 96% of cases (kappa=0.89). Unnecessary transfer to the regional unit was avoided in 93/124 patients (75%). Despite relatively high implementation costs, telemedicine care was substantially cheaper than standard care. Each DGH potentially saved money by utilising the telemedicine service (mean saving: pound728/patient). CONCLUSIONS: CHD is accurately diagnosed by realtime transmission of echocardiograms performed by paediatricians under live guidance and interpretation by a paediatric cardiologist. Remote diagnosis and exclusion of CHD affects patient management and may be cost saving.

Provision of domiciliary dental care in North and West Belfast.

AIM: To determine the level of domiciliary care currently provided for patients by general dental practitioners (GDPs) and to investigate factors that influence the provision of domiciliary dental care in an area of high socioeconomic deprivation in North and West Belfast. METHOD: A descriptive study, involving a self-administered postal questionnaire sent to GDPs (n=89) in North and West Belfast. RESULTS: A valid response rate of 67% was achieved. Almost 20% of responding GDPs reported that they did not routinely offer domiciliary dental care. Of those who did, prosthetic treatment was undertaken most commonly, and other more time-consuming treatments such as fillings were referred to the Community Dental Services (CDS). Many GDPs reported not having a full range of domiciliary equipment, with only half of the GDPs surveyed carrying emergency drugs. Reasons cited for not providing the service were lack of time, the perception that patients would be too difficult to manage, and not having the appropriate equipment. The majority of responding dentists (85%) felt that domiciliary care should be referred to the community service. CONCLUSION: The rate of domiciliary care provision in North and West Belfast appears to be falling, despite it being an area of high socioeconomic deprivation where the demand for the service is growing. The general perception was that domiciliary care is too time-consuming, that the patients are too difficult to manage, and that there was a lack of appropriate equipment. As a result, the majority of GDPs in North and West Belfast felt that the CDS should care for all domiciliary patients.