Exploring Heterogeneity in Cost-Effectiveness Using Machine Learning Methods: A Case Study Using the FIRST-ABC Trial.

OBJECTIVE: The aim of this study was to explore heterogeneity in the cost-effectiveness of high-flow nasal cannula (HFNC) therapy compared with continuous positive airway pressure (CPAP) in children following extubation. DESIGN: Using data from the FIRST-line support for Assistance in Breathing in Children (FIRST-ABC) trial, we explore heterogeneity at the individual and subgroup levels using a causal forest approach, alongside a seemingly unrelated regression (SUR) approach for comparison. SETTINGS: FIRST-ABC is a noninferiority randomized controlled trial (ISRCTN60048867) including children in UK paediatric intensive care units, which compared HFNC with CPAP as the first-line mode of noninvasive respiratory support. PATIENTS: In the step-down FIRST-ABC, 600 children clinically assessed to require noninvasive respiratory support were randomly assigned to HFNC and CPAP groups with 1:1 treatment allocation ratio. In this analysis, 118 patients were excluded because they did not consent to accessing their medical records, did not consent to follow-up questionnaire or did not receive respiratory support. MEASUREMENTS AND MAIN RESULTS: The primary outcome of this study is the incremental net monetary benefit (INB) of HFNC compared with CPAP using a willingness-to-pay threshold of £20,000 per QALY gain. INB is calculated based on total costs and quality adjusted life years (QALYs) at 6 months. The findings suggest modest heterogeneity in cost-effectiveness of HFNC compared with CPAP at the subgroup level, while greater heterogeneity is detected at the individual level. CONCLUSIONS: The estimated overall INB of HFNC is smaller than the INB for patients with better baseline status suggesting that HFNC can be more cost-effective among less severely ill patients.

Parent's preferences for unscheduled paediatric healthcare: A discrete choice experiment.

BACKGROUND: Unscheduled healthcare is a key component of healthcare delivery and makes up a significant proportion of healthcare access, with children being particularly high users of unscheduled healthcare. Understanding the relative importance of factors that influence this behaviour and decision-making is fundamental to ensuring the system is best designed to meet the needs of users and foster appropriate cost-effective usage of health system resources. OBJECTIVE: The aim of the study was to identify the parent's preferences for unscheduled healthcare for a common mild childhood illness. DESIGN: A discrete choice experiment (DCE) was developed to identify the preferences of parents accessing unscheduled healthcare for their children. SETTING AND PARTICIPANTS: Data were collected from parents in Ireland (N = 458) to elicit preferences across five attributes: timeliness, appointment type, healthcare professional attended, telephone guidance before attending and cost. RESULTS: Using a random parameters logit model, all attributes were statistically significant, cost (ß = -5.064, 95% confidence interval, CI [-5.60, -4.53]), same-day (ß = 1.386, 95% CI [1.19, 1.58]) or next-day access (ß = 0.857, 95% CI [0.73, 0.98]), coupled with care by their own general practitioner (ß = 0.748, 95% CI [0.61, 0.89]), identified as the strongest preferences of parents accessing unscheduled healthcare for their children. DISCUSSION: The results have implications for policy development and implementation initiatives that seek to improve unscheduled health services as understanding how parents use these services can maximise their effectiveness. PATIENT OR PUBLIC CONTRIBUTION: The development of the DCE included a qualitative research component to ensure that the content accurately reflected parents experiences when seeking healthcare. Before data collection, a pilot test was carried out with the target population to gather their views on the survey.

Factors that affect GP referral of a child with intellectual disability for a mild illness: A discrete choice experiment.

BACKGROUND: General practitioners (GP) report multiple challenges when treating individuals with intellectual disabilities which may influence referral rates. The study aimed to establish factors that influence GP's decision-making when referring a child with intellectual disabilities to the emergency department. METHOD: Discrete choice experiments (DCEs) are increasingly used in health research to further understand complex decision making. A DCE was designed to assess the relative importance of factors that may influence a GP's (N = 157) decision to refer. RESULTS: A random parameters model indicated that perceived limited parental capacity to manage an illness was the most important factor in the decision to refer a child to the ED, followed by a repeat visit, a referral request from the parent, and a Friday afternoon appointment. CONCLUSION: Understanding the factors that influence referral is important for service improvement and to strengthen primary care provision for this population and their families.

Unscheduled healthcare for children with intellectual disabilities: A systematic scoping review.

BACKGROUND: The provision of unscheduled healthcare for children with intellectual disability is less researched than that focused on hospital settings or for adult services. The aim of the scoping review was to map the evidence base in this area and identify areas for future study. METHOD: A five-stage scoping review framework was adopted. CINAHL, PubMed, SCOPUS, PsycINFO, Embase, ProQuest Dissertation & Theses and Google Scholar were searched. Studies published in English after 1/1/2000 were considered eligible for inclusion. RESULTS: A total of 3158 titles and abstracts were screened, 137 full-text articles were reviewed, and 25 papers met the inclusion criteria. Descriptive themes focused on inequities, needs and experiences of families', poor GP training, and limitations of existing evidence. CONCLUSION: Describing trends in healthcare utilisation by this population is valuable for monitoring quality of healthcare, however, addressing observed inequities will require approaches that recognise specific issues within the health system that result in inequities.

A discrete choice experiment exploring farmer preferences for insurance against extreme weather events.

Agriculture represents one of the most vulnerable sectors to extreme weather events that are projected to increase with climate change. Insurance has been advocated as a more efficient means to ensure financial security to farmers, than post-disaster aid for damages. A potential drawback of insurance however, is that unless carefully designed it could dis-incentivise farmers to engage in wider farm adaptation measures or lead to more risk-taking behaviour. This paper analyses the attractiveness of publicly-backed climate risk insurance offerings to farmers and explores their preferences for elements of insurance schemes that do not negatively affect incentives for wider farm adaptation. Specifically, a discrete choice experiment is used to reveal Irish farmers' preferences for multi-annual insurance contracts and weather-indexed versus traditional indemnity insurance and cost. Results indicate that a majority of farmers are willing to buy publicly-backed insurance for protection from extreme weather events. Younger farmers, farmers who currently have farm insurance, farmers from certain geographical locations and farmers who have been previously affected by extreme weather events are more likely to buy insurance. With respect to the design of insurance schemes, farmers prefer multi-annual coverage versus annual renewal. They also prefer indexed-insurance and have a strong preference for cheaper coverage. Despite the important role that insurance could play in protecting farms financially from damage caused by extreme weather events, few studies have examined preference for weather-indexed insurance within a European context. New evidence on farmer preferences and intended behaviours is therefore critical to inform policy in this area.

Do mothers accurately identify their child's overweight/obesity status during early childhood? Evidence from a nationally representative cohort study.

BACKGROUND: Maternal recognition of overweight/obesity during early childhood is a key determinant in achieving healthy weight status in children. The aim of this study is to 1) investigate maternal perceptions of their child weight, focusing on whether or not mothers accurately identify if their child is overweight or obese at three years old and five years old; 2) identify the factors influencing maternal misperceptions regarding their child's weight at three years old and five years old, 3) ascertain if a failure to recognize overweight/obesity at three years old is associated with the likelihood of doing so at five years old. METHODS: Using two waves of the longitudinal Growing Up in Ireland study data regarding child, maternal, and household characteristics as well as healthcare access and utilization variables were obtained for mothers when their children are three and five years old respectively. Multivariate logistic analysis was used to examine the factors associated with mothers inaccurately perceiving their child to be of normal weight status when the child is in fact either clinically overweight or obese. RESULTS: In wave 2, 22% of mothers failed to accurately identify their child to be overweight or obese. This inaccuracy decreased to 18% in wave 3. A failure of mothers to identify their child's overweight/obesity was more likely to occur if the child was a girl (OR: 1.25) (OR: 1.37), had a higher birth weight (OR:1.00), if the mother was obese (OR: 1.50), (OR: 1.72) or working (OR:1.25) (OR:1.16) in wave 2 and wave 3, respectively. Other factors affecting the odds of misperceiving child's weight include gestation age, income and urban living. CONCLUSION: These findings suggest that mothers of overweight or obese three and five year olds show poor awareness of their child's weight status. Both child and mother characteristics play a role in influencing this awareness. Mothers unable to accurately identify their child's overweight or obesity status at three years old are likely to do again when the child is five years old. This study highlights the need for increased support to help improve mothers' understanding of healthy body size in preschool aged children.

Economic impact of medication error: a systematic review.

PURPOSE: Medication error is a significant source of morbidity and mortality among patients. Clinical and cost-effectiveness evidence are required for the implementation of quality of care interventions. Reduction of error-related cost is a key potential benefit of interventions addressing medication error. The aim of this review was to describe and quantify the economic burden associated with medication error. METHODS: PubMed, Cochrane, Embase, CINAHL, EconLit, ABI/INFORM, Business Source Complete were searched. Studies published 2004-2016 assessing the economic impact of medication error were included. Cost values were expressed in Euro 2015. A narrative synthesis was performed. RESULTS: A total of 4572 articles were identified from database searching, and 16 were included in the review. One study met all applicable quality criteria. Fifteen studies expressed economic impact in monetary terms. Mean cost per error per study ranged from €2.58 to €111 727.08. Healthcare costs were used to measure economic impact in 15 of the included studies with one study measuring litigation costs. Four studies included costs incurred in primary care with the remaining 12 measuring hospital costs. Five studies looked at general medication error in a general population with 11 studies reporting the economic impact of an individual type of medication error or error within a specific patient population. CONCLUSIONS: Considerable variability existed between studies in terms of financial cost, patients, settings and errors included. Many were of poor quality. Assessment of economic impact was conducted predominantly in the hospital setting with little assessment of primary care impact. Limited parameters were used to establish economic impact. Copyright © 2017 John Wiley & Sons, Ltd.

Chronic disease burden associated with overweight and obesity in Ireland: the effects of a small BMI reduction at population level.

BACKGROUND: Overweight and obesity prevalence has risen dramatically in recent decades. While it is known that overweight and obesity is associated with a wide range of chronic diseases, the cumulative burden of chronic disease in the population associated with overweight and obesity is not well quantified. The aims of this paper were to examine the associations between BMI and chronic disease prevalence; to calculate Population Attributable Fractions (PAFs) associated with overweight and obesity; and to estimate the impact of a one unit reduction in BMI on the population prevalence of chronic disease. METHODS: A cross-sectional analysis of 10,364 adults aged ≥18 years from the Republic of Ireland National Survey of Lifestyle, Attitudes and Nutrition (SLÁN 2007) was performed. Using binary regression, we examined the relationship between BMI and the selected chronic diseases. In further analyses, we calculated PAFs of selected chronic diseases attributable to overweight and obesity and we assessed the impact of a one unit reduction in BMI on the overall burden of chronic disease. RESULTS: Overweight and obesity prevalence was higher in men (43.0% and 16.1%) compared to women (29.2% and 13.4%), respectively. The most prevalent chronic conditions were lower back pain, hypertension, and raised cholesterol. Prevalence of chronic disease generally increased with increasing BMI. Compared to normal weight persons, the strongest associations were found in obese women for diabetes (RR 3.9, 95% CI 2.5-6.3), followed by hypertension (RR 2.9, 95% CI 2.3-3.6); and in obese men for hypertension (RR 2.1, 95% CI 1.6-2.7), followed by osteoarthritis (RR 2.0, 95% CI 1.2-3.2). Calculated PAFs indicated that a large proportion of chronic disease is attributable to increased BMI, most noticeably for diabetes in women (42%) and for hypertension in men (30%). Overall, a one unit decrease in BMI results in 26 and 28 fewer cases of chronic disease per 1,000 men and women, respectively. CONCLUSIONS: Overweight and obesity are major contributors to the burden of chronic disease in the population. The achievement of a relatively modest reduction in average BMI in the population has the potential to make a significant impact on the burden of chronic disease.

Heterogeneity within the Oregon Health Insurance Experiment: An application of causal forests.

Existing evidence regarding the effects of Medicaid expansion, largely focused on aggregate effects, suggests health insurance impacts some health, healthcare utilization, and financial hardship outcomes. In this study we apply causal forest and instrumental forest methods to data from the Oregon Health Insurance Experiment (OHIE), to explore heterogeneity in the uptake of health insurance, and in the effects of (a) lottery selection and (b) health insurance on a range of health-related outcomes. The findings of this study suggest that the impact of winning the lottery on the health insurance uptake varies among different subgroups based on age and race. In addition, the results generally coincide with findings in the literature regarding the overall effects: lottery selection (and insurance) reduces out-of-pocket spending, increases physician visits and drug prescriptions, with little (short-term) impact on the number of emergency department visits and hospital admissions. Despite this, we detect quite weak evidence of heterogeneity in the effects of the lottery and of health insurance across the outcomes considered.

Examining labelling effects within discrete choice experiments: an application to recreational site choice.

Data from a discrete choice experiment aimed at eliciting the demand for recreational walking trails on farmland in Ireland is used to explore whether some respondents reach their choices solely on the basis of the alternative's label. To investigate this, this paper exploits a discrete mixtures approach that also encompasses continuous distributions to reflect the heterogeneity in preferences for the attributes and alternatives. We find evidence that a proportion of respondents choose on the basis of the label only and that differences emerge between rural and urban respondents. We provide a number of alternative explanations for why this may occur. Results highlight a large impact on welfare measures when we accommodate the fact that a proportion of respondents choose on the basis of the label only.

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.

The role of contextual factors in decision-making by General Practitioners on paediatric referral to the Emergency Department in Ireland: A Discrete Choice Experiment.

A General Practitioner's (GP) decision to refer a patient to the emergency department (ED) requires consideration of a multitude of factors, and significant variation in GP referral patterns to secondary care has been recorded. This study examines the contextual factors that influence GPs when referring a paediatric patient with potentially self-limiting clinical symptoms to the ED. Utilizing a discrete choice experiment, survey data was collected from GPs in Ireland (n = 142) to elicit factors influencing this decision across five attributes: time/day of visit, repeat presentation, parents' capacity to cope, parent requesting a referral, and access to a paediatric outpatient clinic/day unit. Using mixed logit models, all attributes were statistically significant, with repeat presentation and parents lacking the capacity to cope identified as the strongest contextual factors leading to the decision to refer to the ED. There has been limited exploration of this decision-making process and this study uses a robust design to identify and rank contextual attributes. Enhanced awareness of contextual factors on referral decision-making is crucial to understanding patterns of paediatric unscheduled healthcare and to planning services that respond to parent's and children's needs, whilst allowing GPs to make decisions in the best interest of the child.

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.

Examining the transnational preventive healthcare utilisation of a group of Eastern European migrants living full-time in another European state.

Migrants in Europe are shown to have consistently lower uptake of preventive healthcare compared to European host populations. This paper examines how the transnational preventive care use of Eastern European migrants in their country of origin may be associated with preventive care uptake in their European host country. Preventive care use data in Ireland was collected on 119 Polish migrants and 123 native Irish from June 2018 to September 2019. Preventive care use data was also collected on the Polish migrant group in Poland during the same period. Preventive care use was captured by examining general practitioner visits, blood or urine test uptake, and cancer screening uptake. Probit models were first estimated to examine whether the Polish migrants were more or less likely to have used each service in Ireland than the native Irish. Second, three bivariate probit models were estimated to examine the use of each service by the Polish migrants only in Ireland and Poland as the two dependant variables. The Polish migrants are less likely to have GP visits, blood or urine test uptake, and cancer screening uptake in Ireland compared to the native Irish. The Polish migrants from this study are also shown to potentially substitute blood or urine test uptake in Ireland for uptake in Poland. Transnational ties can determine the preventive care utilisation of migrants in Europe.

Examining the Association between Polish Migrant Status and Health Preferences Using a Novel Application of a Smaller Design EQ-5D-5L Valuation Study.

INTRODUCTION: Migrants have different utilisation of healthcare services and health-related behaviours than host populations. A potential factor that may contribute to the notable differences in healthcare use and health-related behaviours between migrants and host populations is how these groups value health. Those who place a high value on health have greater healthcare-seeking practices than those who do not. OBJECTIVE: The aim of this study was to examine how Polish migrants and native Irish differ in health state utility valuations using a novel application of a smaller design EQ-5D-5L valuation study. METHODS: This study uses health preferences as a predictor of how one values health. We examined the EQ-5D-5L health preferences of 119 Polish migrants and 123 native Irish, both residing full-time in Ireland. To do so, we used a novel application of a smaller design EQ-5D-5L valuation study that consisted of 30 health states and a targeted sampling strategy coupled with a Bayesian statistical nonparametric model. We collected data from June 2018 to September 2019. RESULTS: Our results highlight that Polish migrants and native Irish differ in their health preferences for and valuation of severe health states. Polish migrants place meaningfully higher utility valuations of 0.1 or more on the three most severe health states compared with the native Irish. CONCLUSION: This study can provide an understanding of a potential new factor underpinning some of the disparities in healthcare utilisation and health-related behaviours among migrants and host populations in Europe. This study also provides proof of principle for using a smaller design EQ-5D-5L valuation study to explore differences in health preferences among other minority subgroups, which can otherwise be hard to uncover when using the secondary analysis of national EQ-5D-5L valuation studies.

Health preferences and preventive care utilisation: How EQ-5D-5L health preferences may affect uptake.

Despite the economic and health benefits of preventive care being well established, the uptake of many cost-effective preventive services remains lower than desired in many cases, especially among specific sub-populations. The value an individual places on health can influence their uptake of preventive care. One way to capture the value an individual places on health and future health status is to examine their health preferences. This study used a novel use of EQ-5D-5L health preferences to determine if health preferences are associated with the uptake of a range of preventive care services, including a cancer screening, blood pressure check, cholesterol check, blood test and urine test. We collected EQ-5D-5L composite time trade-off data in 2018/2019 on 242 respondents residing in Ireland. We estimated an initial tobit model to predict an individual's health preference to capture health preferences as a regressor. We then estimated a bivariate probit model to examine the uptake of each preventive service and GP use. Each model controlled for health preferences, education, sex, type of health coverage, self-reported health, employment status, age and marital status. Health preferences are a significant determinant of all five preventive services while controlling for other covariates. The results shows that the higher an individual values good health, the more likely they are to avail of preventive care. Health preferences can be noted as a potential determinant of preventive care use that could guide policy responses seeking to increase demand-side factors for preventive care uptake.

An Exploration on Attribute Non-attendance Using Discrete Choice Experiment Data from the Irish EQ-5D-5L National Valuation Study.

BACKGROUND: Generic measures of health-related quality of life (HRQoL) permit comparisons of competing demands for healthcare resources using outcomes that reflect the preferences of tax payers. EQ-5D instruments are the most commonly used generic, preference-based measures of HRQoL. The EQ-5D-5L enables respondents to describe their health state using five dimensions of health, each with five response levels. The standardised protocol for the valuation of EQ-5D-5L health states comprises use of the composite time trade-off valuation technique, supplemented by a discrete choice experiment (DCE). OBJECTIVE: This paper presents the first exploration on attribute non-attendance (ANA) to the dimensions of the EQ-5D-5L using DCE data collected following the standardised protocol. METHOD: This paper uses the equality constrained latent class model and the endogenous attribute attendance model to examine ANA to the dimensions of the EQ-5D-5L. RESULTS: The results suggest that respondents are less likely to consider the physical dimensions of the EQ-5D-5L (such as self-care and usual activities) when evaluating the health states. The effects of ANA on utility scores depends on the interpretation of the underlying reasons for ANA. CONCLUSIONS: We recommend that future value sets based in whole or in part on DCE data examine the impact of and reasons for non-attendance in national valuation studies.

Supporting family carers of people with dementia: A discrete choice experiment of public preferences.

Community-based care for people with dementia is mainly provided by family carers, many of whom experience decreased mental, physical and financial well-being due to their caring role. Many countries are now implementing ageing-in-place policies that have increased pressure on family carers as care-work is redistributed from residential to community-based settings. Family caring responsibilities for people with dementia are made even more complicated by the economic, social and cultural expectations that underpin existing provision. Support for family carers is, therefore, an important policy topic across many countries. The focus of this paper is on the propensity of citizens to support enhanced care for family carers in Ireland, as demonstrated by their willingness-to-pay additional taxation to fund different combinations of carer support measures, developed through careful and sustained dialogue with multiple stakeholders, especially family carers themselves. We carried out a discrete choice experiment (DCE) with 509 members of the general public in Ireland between January and February 2021. Using mixed logit models, our findings show that citizens value four key attributes: regular caring breaks for family carers (day-care and long-break respite); financial compensation (carer's allowance); and emotional support (carer peer support groups). We also estimated the welfare impact of moving from current provision to enhanced support packages for family carers of people with dementia. The welfare gains accumulate to €1035.80 for the most complete levels of provision across the four support attributes. Overall, respondents in this paper showed empathy and understanding towards family carers of people with dementia through their willingness to contribute to funding additional services and supports.

Preferences for Weight Loss Treatment Amongst Treatment-Seeking Patients with Severe Obesity: A Discrete Choice Experiment.

BACKGROUND: Treatment options for weight loss vary considerably with regard to risks and benefits, but the relative importance of treatment characteristics in patient decision-making is largely unknown, particularly amongst patients with severe obesity. Developing such services requires insight into the preferences of recipients for service attributes. OBJECTIVE: The objective of this study was to quantify, using a discrete choice experiment, the preferences of treatment-seeking patients with severe obesity within the Irish population regarding different attributes of various obesity treatments. METHODS: Within a cohort of patients with severe obesity attending a hospital-based weight management programme, patients' attitudes to and perceptions of three distinct treatment modalities were compared to those regarding not having treatment. The treatments included a structured lifestyle modification programme, lifestyle modification alongside weight loss medication, and bariatric surgery. RESULTS: On average, patients with severe and complicated obesity who were attending a weight management programme were more enthusiastic about participating in a programme to help improve their diet and physical activity than they were about having surgery if the methods of treatment had equivalent results and costs. CONCLUSION: The findings provide insights into preferences that might assist the development of more appropriate treatments for severe obesity.

Budget impact analysis of an early identification and referral model for diagnosing patients with suspected rheumatoid arthritis in Ireland.

OBJECTIVE: To estimate the budget impact from the perspective of the Irish health-care system attributable to a reconfiguration in the diagnostic care pathway for patients with suspected RA by adopting an early identification and referral model (EIM). METHODS: The budget impact model evaluated the total health-care use and costs attributable to an EIM to diagnose patients with suspected RA relative to the reference scenario of current practice. The modelling also assessed a primary outcome of effect, which examined how many patients can be diagnosed by a rheumatologist within 3 months of symptom onset. The budget impact analysis model was estimated over a 5-year time frame. RESULTS: The EIM generated a cost saving for the Irish health-care system of €237 547 over the time frame relative to current practice. The cost savings were realized owing to a reduction in the number of general practitioner (GP) visits of 18 790 and a reduction in diagnostic tests carried out by GPs. The results showed that 1027 (510%) more patients were diagnosed within 3 months of symptom onset in the EIM compared with current practice. CONCLUSION: This paper has presented an alternative rheumatologist-led service design that can be used in diagnosing patients with suspected RA. The rheumatologist-led service provision detailed in this study has the potential simultaneously to reduce demand for primary care services and to improve the health outcomes of patients. The use of an EIM sees rheumatologist activity incorporate patient demand.