Place of Death for Adults Receiving Specialist Palliative Care in Their Last 3 Months of Life: Factors Associated With Preferred Place, Actual Place, and Place of Death Congruence.

Objectives: Congruence between the preferred and actual place of death is recognised as an important quality indicator in end-of-life care. However, there may be complexities about preferences that are ignored in summary congruence measures. This article examined factors associated with preferred place of death, actual place of death, and congruence for a sample of patients who had received specialist palliative care in the last three months of life in Ireland. Methods: This article analysed merged data from two previously published mortality follow-back surveys: Economic Evaluation of Palliative Care in Ireland (EEPCI); Irish component of International Access, Rights and Empowerment (IARE I). Logistic regression models examined factors associated with (a) preferences for home death versus institutional setting, (b) home death versus hospital death, and (c) congruent versus non-congruent death. Setting: Four regions with differing levels of specialist palliative care development in Ireland. Participants: Mean age 77, 50% female/male, 19% living alone, 64% main diagnosis cancer. Data collected 2011-2015, regression model sample sizes: n = 342-351. Results: Congruence between preferred and actual place of death in the raw merged dataset was 51%. Patients living alone were significantly less likely to prefer home versus institution death (OR 0.389, 95%CI 0.157-0.961), less likely to die at home (OR 0.383, 95%CI 0.274-0.536), but had no significant association with congruence. Conclusions: The findings highlight the value in examining place of death preferences as well as congruence, because preferences may be influenced by what is feasible rather than what patients would like. The analyses also underline the importance of well-resourced community-based supports, including homecare, facilitating hospital discharge, and management of complex (eg, non-cancer) conditions, to facilitate patients to die in their preferred place.

Formal health care costs among older people in Ireland: methods and estimates using The Irish Longitudinal Study on Ageing (TILDA).

Background: Reliable data on health care costs in Ireland are essential to support planning and evaluation of services. New unit costs and high-quality utilisation data offer the opportunity to estimate individual-level costs for research and policy. Methods: Our main dataset was The Irish Longitudinal Study on Ageing (TILDA). We used participant interviews with those aged 55+ years in Wave 5 (2018) and all end-of-life interviews (EOLI) to February 2020. We weighted observations by age, sex and last year of life at the population level. We estimated total formal health care costs by combining reported usage in TILDA with unit costs (non-acute care) and public payer reimbursement data (acute hospital admissions, medications). All costs were adjusted for inflation to 2022, the year of analysis. We examined distribution of estimates across the population, and the composition of costs across categories of care, using descriptive statistics. We identified factors associated with total costs using generalised linear models. Results: There were 5,105 Wave 5 observations, equivalent at the population level to 1,207,660 people aged 55+ years and not in the last year of life, and 763 EOLI observations, equivalent to 28,466 people aged 55+ years in the last year of life. Mean formal health care costs in the weighted sample were EUR 8,053; EUR 6,624 not in the last year of life and EUR 68,654 in the last year of life. Overall, 90% of health care costs were accounted for by 20% of users. Multiple functional limitations and proximity to death were the largest predictors of costs. Other factors that were associated with outcome included educational attainment, entitlements to subsidised care and serious chronic diseases. Conclusions: Understanding the patterns of costs, and the factors associated with very high costs for some individuals, can inform efforts to improve patient experiences and optimise resource allocation.

The price of private dental services: results from a national representative survey of Ireland.

INTRODUCTION: Dental services in Ireland are delivered in a mixed public-private system but the majority of dental care is paid for out-of-pocket by individuals. Ireland is not unusual in the global context where public subsidisation for oral healthcare is limited in many countries. This is despite the fact that oral health plays an important role in well-being and despite international evidence on the negative impact of user fees on utilisation of beneficial healthcare. However, there has been little up-to-date assessment of the prices faced by individuals for a range of non-acute care services in Ireland, including dental care. This paper presents an up-to-date assessment of private dental prices in Ireland for a range of preventive, primary, and complex services based on a nationally representative survey. METHODS: The total sample size for the desk-based survey was 103, accounting for 6% of private dentists in Ireland, weighted to reflect the geographic distribution of dentists. Dentists were selected at random from the publicly available list of dentists participating in the Dental Treatment Benefit Scheme. The adult price of 10 different services covering core preventive, primary, and complex procedures were identified from public websites for the selected dental practices. RESULTS: Results showed that in addition to there being an uneven supply of dentists across the country, dental prices also vary with some notable variations by region and type of service. In particular, dental practices located in border counties, and those in rural areas typically show lower mean prices relative to non-border counties and urban areas. These factors need to be considered when planning how to reduce inequalities in access to oral health services in Ireland.

Evaluating a community respiratory physiotherapy service for children with neurodisability.

BACKGROUND: Children with neurodisability are at an increased risk of respiratory problems and complications, which often result in prolonged, frequent hospital admissions and are the biggest cause of mortality in this client group. The Children's Community Respiratory Physiotherapy Service (CCRPS) was established in 2010 to support children with severe neurodisabilities at home during acute chest infections and to prevent emergency department attendances and hospital admissions. This service evaluation looked at patient/parent satisfaction and prevented admissions to ensure clinical and cost-effectiveness, despite the rising demand for the service. METHODS: Over a 3-month period, patients and parents/carers on the CCRPS caseload were given a Picker feedback survey following 100 emergency visits from the team. The number of prevented hospital admissions for respiratory tract infection over 12 months (April 2019-March 2020) was identified from existing CCRPS data and hospital admissions costs saved were estimated. RESULTS: The Picker survey responses were extremely positive with all respondents reporting that they felt well looked after and that the main reason for the emergency visit was dealt with well. Based on key indicators, the CCRPS prevented 182 hospital admissions for respiratory tract infection in 2019/2020, equating to 1638 bed days and estimated cost savings ranging between £751 728 and £1 009 986. CONCLUSIONS: The Picker survey response demonstrates the positive impact that the CCRPS has on both quality of life and experience for patients and families. The CCRPS rapid response service prevents hospital admissions for respiratory tract infections in children and young people with severe neurodisability and the cost savings from admissions prevented allows the service to more than pay for itself.

Maternity Waiting Home Interventions as a Strategy for Improving Birth Outcomes: A Scoping Review and Meta-Analysis.

BACKGROUND AND OBJECTIVE: Over 300 000 women worldwide die due to pregnancy-related complications annually, with most occurring in developing countries where access to skilled obstetric care is limited. Maternity waiting homes (MWHs) are one intervention designed to increase access to skilled prenatal care in resource-limited settings. MWHs are defined as accommodations at or near a health facility where pregnant women can stay in the final weeks of their pregnancy so they can be easily transferred to the health facility to give birth. While MWHs have existed for decades, evidence regarding their effectiveness in reducing adverse birth outcomes has been mixed. The objective of this study is to comprehensively assess all available MWH research reporting quantitative maternal and childbirth data to determine whether MWHs are an effective maternal health strategy in resource-limited settings. METHODOLOGY: We conducted a scoping review and meta-analysis of existing literature on MWHs according to PRISMA guidelines. Descriptive statistics and odds ratios were calculated for the following birth outcomes: maternal mortality, perinatal mortality, and caesarian section. Quantitative analysis was conducted in RStudio and Stata Version 16. RESULTS: One hundred seventy-one records were retrieved from our initial database search, of which 66 were identified as relevant. Only 15 of these records reported quantitative data on the health outcomes of interest and therefore met inclusion criteria for our meta-analysis. All studies reporting maternal mortality demonstrated a protective effect of MWHs (aggregate OR: 0.19 [0.10, 0.40]), as did all studies reporting perinatal mortality (aggregate OR: 0.29 [0.16, 0.53]). Studies reporting caesarian section were more varied and indicated less of a protective effect (aggregate OR: 1.80 [1.18, 2.75]). CONCLUSIONS: There is some indication that MWHs are an effective strategy for reducing maternal and perinatal mortality in resource-limited settings. However, our analysis was constrained by the observational design of most prior MWH studies. More rigorous MWH evaluations, ideally in the form of randomized-control trials, are needed to better determine MWH effectiveness.

Reliability of assessment of medical students' non-technical skills using a behavioural marker system: does clinical experience matter?

Introduction: Non-technical skills are recognised to play an integral part in safe and effective patient care. Medi-StuNTS (Medical Students' Non-Technical Skills) is a behavioural marker system developed to enable assessment of medical students' non-technical skills. This study aimed to assess whether newly trained raters with high levels of clinical experience could achieve reliability coefficients of >0.7 and to compare differences in inter-rater reliability of raters with varying clinical experience. Methods: Forty-four raters attended a workshop on Medi-StuNTS before independently rating three videos of medical students participating in immersive simulation scenarios. Data were grouped by raters' levels of clinical experience. Inter-rater reliability was assessed by calculating intraclass correlation coefficients (ICC). Results: Eleven raters with more than 10 years of clinical experience achieved single-measure ICC of 0.37 and average-measures ICC of 0.87. Fourteen raters with more than or equal to 5 years and less than 10 years of clinical experience achieved single-measure ICC of 0.09 and average-measures ICC of 0.59. Nineteen raters with less than 5 years of clinical experience achieved single-measure ICC of 0.09 and average-measures ICC 0.65. Conclusions: Using 11 newly trained raters with high levels of clinical experience produced highly reliable ratings that surpassed the prespecified inter-rater reliability standard; however, a single rater from this group would not achieve sufficiently reliable ratings. This is consistent with previous studies using other medical behavioural marker systems. This study demonstrated a decrease in inter-rater reliability of raters with lower levels of clinical experience, suggesting caution when using this population as raters for assessment of non-technical skills.

Unit costs for non-acute care in Ireland 2016-2019.

Background: This paper presents detailed unit costs for 16 healthcare professionals in community-based non-acute services in Ireland for the years 2016-2019. Unit costs are important data inputs for assessments of health service performance and value for money. Internationally, while some countries have an established database of unit costs for healthcare, there is need for a more coordinated approach to calculating healthcare unit costs. In Ireland, detailed cost analysis of acute care is undertaken by the Healthcare Pricing Office but to date there has been no central database of unit costs for community-based non-acute healthcare services. Methods: Unit costs for publicly employed allied healthcare professionals, Public Health Nurses and Health Care Assistant staff are calculated using a bottom-up micro-costing approach, drawing on methods outlined by the Personal Social Services Research Unit in the UK, and on available Irish and international costing guidelines. Data on salaries, working hours and other parameters are drawn from secondary datasets available from Department of Health, Health Service Executive and other public sources. Unit costs for public and private General Practitioner, dental, and long-term residential care (LTRC) are estimated drawing on available administrative and survey data. Results: The unit costs for the publicly employed non-acute healthcare professionals have changed by 2-6% over the timeframe 2016-2019 while larger percentage changes are observed in the unit costs for public GP visits and public LTRC (14-15%). Conclusions: The costs presented here are a first step towards establishing a central database of unit costs for non-acute healthcare services in Ireland. The database will help ensure consistency across Irish health costing studies and facilitate cross-study and cross-country comparisons. Future work will be required to update and expand on the range of services covered and to incorporate new data and methodological developments in cost estimation as they become available.

Geographic inequalities in non-acute healthcare supply: evidence from Ireland.

Background: Recent reforms in Ireland, as outlined in Sláintecare, the report of the cross-party parliamentary committee on health, are focused on shifting from a hospital-centric system to one where non-acute care plays a more central role. However, these reforms were embarked on in the absence of timely and accurate information about the capacity of non-acute care to take on a more central role in the system. To help address this gap, this paper outlines the most comprehensive analysis to date of geographic inequalities in non-acute care supply in Ireland. Methods: Data on the supply of 10 non-acute services including primary care, allied health, and care for older people, were collated. Per capita supply for each service is described for 28 counties in Ireland (Tipperary and Dublin divided into North and South), using 2014 supply and population data. To examine inequity in the geographic distribution of services, raw population in each county was adjusted for a range of needs indicators. Results: The findings show considerable geographic inequalities across counties in the supply of non-acute care. Some counties had low levels of supply of several types of non-acute care. The findings remain largely unchanged after adjusting for need, suggesting that the unequal patterns of supply are also inequitable. Conclusions: In the context of population changes and the influence of non-need factors, the persistence of historical budgeting in Ireland has led to considerable geographic inequities in non-acute supply, with important lessons for Ireland and for other countries. Such inequities come into sharp relief in the context of COVID-19, where non-acute supply plays a crucial role in ensuring that acute services are preserved for treating acutely ill patients.

Meeting the needs of homeless people attending the emergency department.

Homelessness is on the rise in the UK and, over the past few years, there has been a significant increase in the number of emergency department (ED) attendances and admissions by homeless people. Those attending the ED will often have multiple unmet health, housing and social care needs. While it is not possible to meet all these needs in the ED, emergency nurses should be equipped with the knowledge and skills required to communicate with, refer and signpost patients who are homeless. Under the Homelessness Reduction Act 2017, ED staff have a duty to refer homeless people, with their consent, to local authorities for assistance. This article details the barriers that homeless people may experience when accessing healthcare services and explains how these can be addressed. It also outlines the actions that emergency nurses can take to improve the care of homeless people in the ED at an individual and a systems level.

Re-thinking unmet need for health care: introducing a dynamic perspective.

There is an increasing interest in assessing unmet need for health care services particularly in European countries. Despite this there has been relatively little analysis of unmet need in the European or wider international setting. It remains a challenge to pin down what types of unmet need can and should be addressed by health care policymakers, and how to go about identifying and quantifying those unmet needs. The objective of this paper is to propose a new way of thinking about unmet need for health care which can in turn guide analysis of unmet need in terms of potential data sources and analytic approaches. Unmet need is shown to be a complex multi-faceted concept that cannot be captured by a single indicator or measurement. To advance the literature in this field, this paper considers what happens to unmet need over time. By introducing a dynamic perspective, three alternative trajectories for health care needs are outlined: non-use of health care, delayed use of health care and sub-optimal use of health care. These trajectories are discussed with a view to improving the focus, and policy applicability, of empirical research in this field.

"The coupons and stuff just made it possible": economic constraints and patient experiences of a produce prescription program.

Although produce prescription (PRx) programs have been shown to improve fruit and vegetable (FV) consumption, few studies have examined how economic constraints influence participant experience. We conducted a qualitative study of patient experience of a 3-month PRx program for hypertension (PRxHTN) including 3 safety-net clinics and 20 farmers' markets (FMs). We interviewed 23 PRxHTN participants using semistructured guides to understand their program experiences. Interviews were audio-taped, transcribed, and analyzed to identify a priori and emergent themes. PRxHTN participants completing qualitative interviews were mostly middle-aged (mean: 62 years) African American (100%) women (78%). Economic hardship as a barrier to maximum program participation and sustainability was a main theme identified, with three subthemes: (i) transportation issues shaped shopping and eating patterns and limited participant ability to access FMs to utilize PRxHTN vouchers; (ii) limited and unstable income shaped participant shopping and eating behavior before, during, and after PRxHTN; and (iii) participants emphasized individual-level influences like personal or perceived motivations for program participation, despite significant structural constraints, such as economic hardship, shaping their program engagement. Future PRx programs should bolster economic and institutional supports beyond FM vouchers such as transportation assistance, partnering with local food banks and expansion to local grocery stores offering year-round FV access to support sustained behavior change. Additionally, structural competency tools for providers may be warranted to reorient focus on structural influences on program engagement and away from potentially stigmatizing individual-level explanations for program success. These efforts have potential to enhance the translation of PRx programs to the needs of economically vulnerable patients who struggle to manage chronic illness and access basic nutrition.

A profile of physiotherapy supply in Ireland.

BACKGROUND: The lack of information on public and private physiotherapy supply in Ireland makes current and future resource allocation decisions difficult. AIM: This paper estimates the supply of physiotherapists in Ireland and profiles physiotherapists across acute and non-acute sectors, and across public and private practice. It examines geographic variation in physiotherapist supply, examining the implications of controlling for healthcare need. METHODS: Physiotherapist headcounts are estimated using Health Service Personnel Census (HSPC) and Irish Society of Chartered Physiotherapists (ISCP) Register data. Headcounts are converted to whole-time equivalents (WTEs) using the HSPC and a survey of ISCP members to account for full- and part-time working practices. Non-acute supply per 10,000 population in each county is estimated to examine geographic inequalities and the raw population is adjusted in turn for a range of need indicators. RESULTS: An estimated 3172 physiotherapists were practising in Ireland in 2015; 6.8 physiotherapists per 10,000, providing an estimated 2620 WTEs. Females accounted for 74% of supply. Supply was greater in the non-acute sector; 1774 WTEs versus 846 WTEs in the acute sector. Physiotherapists in the acute sector were located mainly in publicly financed institutions (89%) with an even public/private split observed in the non-acute sector. Non-acute physiotherapist supply is unequally distributed across Ireland (Gini coefficient = 0.12; 95% CI 0.08-0.15), and inequalities remain after controlling for variations in healthcare needs across counties. CONCLUSION: The supply of physiotherapists in Ireland is 30% lower than the EU-28 average. Substantial inequality in the distribution of physiotherapists across counties is observed.

Dietary Impact of Produce Prescriptions for Patients With Hypertension.

INTRODUCTION: Little is known regarding the impact of produce prescriptions within the context of hypertension visits at safety net clinics. We evaluated intervention effectiveness on patient usage of farmers markets and dietary change related to fruit and vegetable consumption. METHODS: Health Improvement Partnership - Cuyahoga worked with 3 clinics to integrate, implement, and evaluated a produce prescription for hypertension (PRxHTN) program. PRxHTN involves 3 monthly, nonphysician provider visits, comprising blood pressure measurement, nutrition counseling, and four $10 farmers market produce vouchers, for hypertensive adult patients screening positive for food insecurity. Dietary measures were collected at visits 1 and 3. Voucher use was tracked via farmers market redemption logs. RESULTS: Of the 224 participants from 3 clinics, most were middle-aged (mean age, 62 y), female (72%), and African American (97%) and had a high school education or less (62%). Eighty-six percent visited a farmers market to use their produce vouchers, with one-third reporting it was their first farmers market visit ever. Median number of farmers market visits was 2 (range: 0-6), and median number of vouchers redeemed was 8 (range: 0-12). Among the subsample with follow-up survey data (n = 137), significant improvement in fruit and vegetable consumption was observed as well as a decline in fast food consumption. CONCLUSION: PRxHTN participants visited at least 1 farmers market, reported increases in provider communication related to diet, and exhibited significant changes in dietary behavior. PRxHTN can serve as a strong model for linking safety net clinics with farmers markets to promote community resource use and improve fruit and vegetable consumption among food-insecure patients with hypertension.

Costs of formal and informal care in the last year of life for patients in receipt of specialist palliative care.

BACKGROUND: Economic evaluation of palliative care has been slow to develop and the evidence base remains small. AIM: This article estimates formal and informal care costs in the last year of life for a sample of patients who received specialist palliative care in three different areas in Ireland. DESIGN: Formal care costs are calculated for community, specialist palliative care, acute hospital and other services. Where possible, a bottom-up approach is used, multiplying service utilisation by unit cost. Informal care is valued at the replacement cost of care. SETTING/PARTICIPANTS: Data on utilisation were collected during 215 'after death' telephone interviews with a person centrally involved in the care in the last year of life of decedents who received specialist palliative care in three areas in Ireland with varying levels of specialist palliative care. RESULTS: Mean total formal and informal costs in the last year of life do not vary significantly across the three areas. The components of formal costs, however, do vary across areas, particularly for hospital and specialist palliative care in the last 3 months of life. CONCLUSION: Costs in the last year of life for patients in receipt of specialist palliative care are considerable. Where inpatient hospice care is available, there are potential savings in hospital costs to offset specialist palliative care inpatient costs. Informal care accounts for a high proportion of costs during the last year of life in each area, underlining the important role of informal caregivers in palliative care.

Smoke-Free Public Policies and Voluntary Policies in Personal Settings in Tbilisi, Georgia: A Qualitative Study.

Georgia has limited tobacco control policies, particularly in the area of smoke-free public policies, which may influence the adoption of smoke-free home rules. We qualitatively examined knowledge about and reactions to public and personal smoke-free policies among Tbilisi residents. In Spring 2014, we conducted six focus groups among 47 total participants--two among male smokers, one among male nonsmokers, two among female smokers, and one among female nonsmokers. Our sample was 48.9% male and 70.2% past 30-day smokers. Most believed that SHS was dangerous, with particular concern regarding the impact of SHS on children and pregnant women. Many had misconceptions about how to protect others from SHS and the effectiveness of some approaches. Many indicated that they had some type of home rules, but few reported a complete ban on smoking in the home. Even when some restrictions were in place, they rarely were effective or enforced. Common concerns about the partial smoke-free public policy in Georgia included its economic impact, perceived discrimination among smokers, and the policy being against the Georgian culture. These concerns were heightened when participants were asked about the possible implementation of a complete smoke-free policy. Educational programs are needed to promote smoke-free policies in Georgia.

Acute hospital, community, and indirect costs of stroke associated with atrial fibrillation: population-based study.

BACKGROUND AND PURPOSE: No economic data from population-based studies exist on acute or late hospital, community, and indirect costs of stroke associated with atrial fibrillation (AF-stroke). Such data are essential for policy development, service planning, and cost-effectiveness analysis of new therapeutic agents. METHODS: In a population-based prospective study of incident and recurrent stroke treated in hospital and community settings, we investigated direct (healthcare related) and indirect costs for a 2-year period. Survival, disability, poststroke residence, and healthcare use were determined at 90 days, 1 year, and 2 years. Acute hospital cost was determined using a case-mix approach, and other costs using a bottom-up approach (2007 prices). RESULTS: In 568 patients ascertained in 1 year (2006), the total estimated 2-year cost was $33.84 million. In the overall sample, AF-stroke accounted for 31% (177) of patients, but a higher proportion of costs (40.5% of total and 45% of nursing home costs). On a per-patient basis compared with non-AF-stroke, AF-stroke was associated with higher total (P<0.001) and acute hospital costs (P<0.001), and greater nursing home (P=0.001) and general practitioner (P<0.001) costs among 90-day survivors. After stratification by stroke severity in survivors, AF was associated with 2-fold increase in costs in patients with mild-moderate (National Institutes of Health Stroke Scale, 0-15) stroke (P<0.001) but not in severe stroke (National Institutes of Health Stroke Scale ≥16; P=0.7). CONCLUSIONS: In our population study, AF-stroke was associated with substantially higher total, acute hospital, nursing home, and general practitioner costs per patient. Targeted programs to identify AF and prevent AF-stroke may have significant economic benefits, in addition to health benefits.

Understanding and measuring health care insecurity.

PURPOSE: To define the concept of "health care insecurity," validate a new self-report measure, and examine the impact of beginning care at a free clinic on uninsured patients' health care insecurity. METHODS: Consecutive new patients presenting at a free clinic completed 15 items assessing domains of health care insecurity (HCI) at their first visit and again four to eight weeks later. Psychometrics and change of the HCI measure were examined. RESULTS: The HCI measure was found to have high internal consistency (α=0.94). Evidence of concurrent validity was indicated by negative correlation with VR-12 health-related quality of life physical and mental health components and positive correlation with the Perceived Stress Scale. Predictive validity was shown among the 83% of participants completing follow-up: HCI decreased after beginning care at a free clinic (p<.001). CONCLUSION: Reliably assessing patient experience of health care insecurity is feasible and has potential to inform efforts to improve quality and access to care among underserved populations.

Creating a culture of inquiry in family medicine.

BACKGROUND AND OBJECTIVES: Strengthening the contribution of reflective practice and new knowledge generation to the learning relationships forged during graduate and undergraduate medical training offers a possibility to create a climate more conducive to the recruitment and retention of family physicians. The Culture of Inquiry (CI) fellowship, an immersive, experientially based training program, combines didactic instruction, workshops, and mentoring to develop the capacity of family medicine's teachers to imagine, implement, and disseminate clinically relevant research and stimulate collaborations with those whom they train. This article outlines the CI fellowship program, summarizes its outcomes, and offers insights about programmatic features contributing to its success. METHODS: The Department of Family Medicine and Community Health at Case Western Reserve University selected CI fellows from interested local family physicians who train residents and medical students. Over 10 months, with 10% effort expected from fellows, the CI fellowship exposed each fellow to the entire research process and provided technical and logistical support for the design and completion of two research projects. Quantitative and qualitative program evaluation were used to assess outcomes. RESULTS: Scholarly productivity of fellows exceeded expectations. Collaborations with students and residents produced a ripple effect that amplified the fellowship's impact by strengthening those relationships crucial to the creation of a culture of inquiry among family medicine's teachers, learners, and practitioners. CONCLUSIONS: The CI fellowship represents a highly replicable program to connect committed and interested clinicians to research mentors with the goal of increasing scholarship and creating a growing culture of inquiry in family medicine.

Teachable moments for health behavior change and intermediate patient outcomes.

OBJECTIVE: Teachable moments (TM) are opportunities created through physician-patient interaction and used to encourage patients to change unhealthy behaviors. We examine the effectiveness of TMs to increase patients' recall of advice, motivation to modify behavior, and behavior change. METHODS: A mixed-method observational study of 811 patient visits to 28 primary care clinicians used audio-recordings of visits to identify TMs and other types of advice in health behavior change talk. Patient surveys assessed smoking, exercise, fruit/vegetable consumption, height, weight, and readiness for change prior to the observed visit and 6-weeks post-visit. RESULTS: Compared to other identified categories of advice (i.e. missed opportunities or teachable moment attempts), recall was greatest after TMs occurred (83% vs. 49-74%). TMs had the greatest proportion of patients change in importance and confidence and increase readiness to change; however differences were small. TMs had greater positive behavior change scores than other categories of advice; however, this pattern was statistically non-significant and was not observed for BMI change. CONCLUSION: TMs have a greater positive influence on several intermediate markers of patient behavior change compared to other categories of advice. PRACTICE IMPLICATIONS: TMs show promise as an approach for clinicians to discuss behavior change with patients efficiently and effectively.

Evidence on the cost and cost-effectiveness of palliative care: a literature review.

BACKGROUND: 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. AIM: 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. DESIGN: Key bibliographic and review databases were searched. Quality of retrieved papers was assessed against a set of 31 indicators developed for this review. DATA SOURCES: PubMed, EURONHEED, the Applied Social Sciences Index and the Cochrane library of databases. RESULTS: 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. CONCLUSION: 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.