Estimating the health-care costs of wound care in Ireland.

OBJECTIVE: To estimate the cost of wound care to the Irish health-care system. METHODS: A bottom-up, prevalence-based analysis was undertaken using a decision analytic model to estimate costs. Health-care resource activity was identified from a recently published study from the UK and was valued using unit cost data for Ireland. RESULTS: The base case analysis estimated the total annual healthcare cost of wound care to be €629,064,198 (95% Confidence interval (CI): €452,673,358 to €844,087,124), accounting for 5% (95% CI: 3% to 6%) of total public health expenditure in Ireland in 2013. The average cost per patient was €3,941 (95% CI: €2,836 to €5,287). However, this study is subject to many limitations and plausible changes in the model's inputs showed that the total annual health-care cost of wound care could range from €281,438,970 to €844,316,912. CONCLUSION: Caring for wounds places a substantial burden on the Irish health-care system. In light of growing pressures to finance an already resource-constrained health-care system, these results provide useful information for those charged with future wound care service design and provision in Ireland and elsewhere.

The sustainability of a community nurses programme aimed at supporting active ageing in mountain areas.

BACKGROUND: Community Nurse Supporting Elderly iN a changing SOciety is a project funded by the European Union, which is aimed at developing an innovative care model based on community nurses to support active ageing in mountain areas. The planned sustainability of this innovative approach relies on social entrepreneurship, and this work highlights the necessary conditions for the existence of these entrepreneurial initiatives on the market, with community nurses' services purchased by the public health care system. METHODS: The authors propose a sustainability framework for this project based on three relevant dimensions (ie, health, organisation, and context), highlighting the necessary conditions for continued provision of health services beyond project conclusion. Then, considering the Piedmont Region and those aged 65 or older as target population, health outcomes are analysed, proposing a break-even analysis to calculate expected levels. RESULTS: According to our results, in order to care for 191 977 elderly people for 3 years, a successful pro-active approach is needed to prevent 1657 falls with hip fracture, reducing the prevalence of this adverse outcome by 36%. These are the expected health outcome levels for the existence of a social market, which can be achieved through the successful involvement of local public health organisations and stakeholders. CONCLUSIONS: Policy makers need clear information on the economic impact of extending this new intervention to the whole target population and on the required preconditions for its financial sustainability in terms of health outcomes. However, a participatory process involving all relevant local stakeholders and organisations is crucial to extend current achievements beyond project conclusion.

Urinary catheter-related visits to the emergency department and implications for community services.

Thousands of patients live with urinary catheters and the potential complications deriving from long-term use. Disjointed community services may result in patients attending the emergency department (ED) to manage catheter complications. AIM: to conduct a service review of catheterised patients attending the ED of a large London hospital; to describe incidence, reasons for attendance and cost to inform future planning for out-of-hospital care. METHOD: a catheter collaborative, consisting of multidisciplinary health professionals and patients, formulated survey questions. Patients were identified from the electronic patient record by searching for the code 'urological complaint'. One month of clinical records were retrospectively reviewed and analysed using descriptive statistics. RESULTS: 287 patients attended the department with urological complaints: 41 (14%) had urinary catheter problems, of these 24 (59%) patients were discharged and 17 (41%) were admitted for further treatment. Stays in ED varied from 1 hour 13 minutes to 17 hours (mean = 4.8 hours). A total of 9 patients (38%) were sent home during antisocial hours (9 pm to 7 am), 4 patients were discharged between midnight and 2 am. Patients admitted had mean stays of 4.11 days. Most admissions were short term for intravenous (IV) treatments; 3 patients were hospitalised for 20 days. A total of 14 patients (34%) were diagnosed with catheter-related infections: 11 (79%) had bladder infections and 3 (21%) had septicaemia. All 14 patients (100%) had urine-culture-confirmed infections, mainly from coliform, proteus and pseudomonas species. A total of 20 patients (49%) received antibiotic treatment. The majority of patients received an initial IV dose followed, where required, by oral treatment on discharge. CONCLUSIONS: many catheterised patients had complex needs with high rates of urinary infections and admissions for urosepsis. High attendance related less to old age but more to complexity of history, such as neurological conditions and disability. Only a proportion of these patients could be safely treated by district nurse teams. A significant proportion would require more responsive community services with several spells of short-term input (e.g. daily or more than once-daily visits) and access to diagnostics, microbiology, pharmaceutical input and IV treatments.

Multicentre observational study of outcomes after drainage of acute perianal abscess.

INTRODUCTION: Management of perianal abscesses has remained largely unchanged for over 50 years. The evidence for postoperative wound packing is limited and may expose patients to painful procedures with no clinical benefit and at considerable increased cost. METHODS: Patients were recruited in 15 UK centres between December 2013 and October 2014. Outcome measures included number of dressing (pack) changes, healing, recurrence, return to work/normal function, postoperative fistula in ano and health utility scores (EQ-5D™). Pain was measured before, during and after dressing change on a visual analogue scale. RESULTS: Some 141 patients were recruited (median age 39 (range 18-86) years). The mean number of dressing changes in the first 3 weeks was 13 (range 0-21), equating to an annual cost to the National Health Service of €6 453 360 in England alone per annum. Some 43·8 per cent of wounds were healed by 8 weeks after surgery and 86 per cent of patients had returned to normal function. Some 7·6 per cent of abscesses had recurred and 26·7 per cent of patients developed a fistula in ano by 6 months following surgery. Patients reported a twofold to threefold increase in pain scores during and after dressing changes. CONCLUSION: Recurrent abscess is rare and fistula occurs in one-quarter of the patients. Packing is painful and costly.

IV antibiotic therapy in the community: clinically effective and cost effective.

This article discusses how the introduction of new ways of working has resulted in a more cost-effective service for the delivery of intravenous (IV) antibiotic therapy in a community setting. When community IV therapy was originally initiated in the trust, the system involved two nurses to check calculations and oversee the administration of IV antibiotic therapy. However, as the demand for IV therapy escalated, and with some patients requiring multiple visits, pressures on community nursing teams created challenges relating to capacity and demand. This service improvement project involved two phases. Phase one examined patient safety and the administration of IV antibiotics by one nurse. Phase two reviewed the administration of IV antibiotic via a timed bolus route. Following the analysis, the implementation of these initiatives demonstrated maximisation of resources, a release of nurses' time to care and improvements to the patient experience.

Comparison of sole nurse and team-delivered community clozapine services for people with treatment-resistant schizophrenia.

AIM: To compare sole nurse and doctor-led multidisciplinary team delivery of community clozapine services for people with treatment-resistant schizophrenia. BACKGROUND: Around 20% of people with schizophrenia are treatment resistant and fail to respond to front line medications. Clozapine, a second-line treatment, has potentially serious side effects requiring regular monitoring. Different models of community clozapine services are emerging in the British National Health Service, but there is little evidence about which is best. DESIGN: Questionnaire survey of service users. METHODS: All patients on the lists of seven clozapine clinics (four sole nurse, three multidisciplinary team) in one trust were invited to participate, 2009-2010. Forward stepwise regression was used to investigate associations between patient well-being, functioning, self-efficacy and satisfaction, and clinic model attended, controlling for socio-demographic and health characteristics and processes of care. Use (and costs) of other health and social services accessed was compared between models. RESULTS: Sixty-six service users (35% participation rate) responded. Well-being and functioning were associated with patient characteristics and processes of care, not clinic model. Patients managed by sole nurses reported, over 3 months: more community psychiatric nurse visits and hospital psychiatrist appointments. Clinic list size affects costs per patient. CONCLUSIONS: Multidisciplinary team delivery may reduce use of other services. Although multidisciplinary team delivery is regarded as best practice, sole nurses can effectively provide clozapine services and may be warranted in areas of low population density.

Community Engagement: Leveraging Resources to Improve Health Outcomes.

Improving the health of communities requires creating partnerships and leveraging partner resources. Engagement with key stakeholders or partners who engage in collaborative community needs assessments has been linked to improved community health outcomes. Understanding how to engage community stakeholders, identify mutual goals, and establish a shared vision can maximize resources to improve the community's health. We applied our experience to an existing model for community engagement and leveraging of resources to improve the community's health and translate the model to a community case.

Avoiding inappropriate paediatric admission: facilitating General Practitioner referral to Community Children's Nursing Teams.

BACKGROUND: Children's emergency admissions in England are increasing. Community Children's Nursing Teams (CCNTs) have developed services to manage acutely ill children at home to reduce demand for unscheduled care. Referral between General Practitioners (GPs) and CCNTs may reduce avoidable admissions and minimise the psychosocial and financial impact of hospitalisation on children, families and the NHS. However, facilitators of GP referral to CCNTs are not known. The aim of this study was to identify facilitators of GP referral to CCNTs. METHODS: Semi-structured interviews with 39 health professionals were conducted between June 2009 and February 2010 in three Primary Care Trusts served by CCNTs in North West England. Interviewees included GPs, Community Children's Nurses (CCNs), consultant paediatricians, commissioners, and service managers. Qualitative data were analysed thematically using the Framework approach in NVivo 8. RESULTS: Five facilitators were identified: 1) CCN/CCNT visibility; 2) clear clinical governance procedures; 3) financial and organisational investment in the role of CCNTs in acute care pathways; 4) access and out of hours availability; 5) facilitative financial frameworks. CONCLUSION: GPs required confidence in CCNs' competence to safely manage acutely ill children at home and secure rapid referral if a child's condition deteriorated. Incremental approaches to developing GP referral to CCNTs underpinned by clear clinical governance protocols are likely to be most effective in building GP confidence and avoiding inappropriate admission.

Comparison of the costs of care during acute illness by two community children's nursing teams.

OBJECTIVE: To compare the costs associated with care by two community children's nursing teams (CCNT). DESIGN: A case study incorporating questionnaire survey, analysis of routinely collected data and analysis of costs in the north-west England. PATIENTS: Children with acute illness referred for CCNT care. INTERVENTIONS: Two CCNT provided care for 273 children during acute illness in order to reduce the number and duration of hospital admissions. MAIN OUTCOME MEASURES: Costs of CCNT, other services and costs to families. RESULTS: The objectives of both CCNT included shortening and avoiding hospitalisations. Most (45 (58%) in case A and 150 (77%) in case B) children were referred for infections. There were differences in the proportion of children who had been hospitalised (45 (57.7%) and 78 (40%)), the mean number of services used before referral to CCNT (1.6 and 2.2) and the staffing profile of the CCNT. There was a statistically significant difference in the overall mean cost to the NHS of CCNT care (£146 and £238, 95% CI for difference of means 7 to 184), associated with higher proportions of children having telephone-only contact (two (3%) and 46 (24%)) and children using almost twice as many other health services during care by one CCNT (means 0.27 and 0.51). CONCLUSIONS: Costs of CCNT care can vary widely when all health service use is taken into account. Differences in the way CCNT are integrated with the urgent care system, and the way in which CCNT care is organised, could contribute to variations in costs.

Experiences implementing a 6-month pilot of a 7-day community CNS service in an urban hospice in Scotland.

BACKGROUND: Patients and carers may face challenges in the out-of-hours period, with inadequate support and variations in service provision, including access to specialist palliative care. A pilot was undertaken to extend availability of the community clinical nurse specialist (CNS) team to include weekends and public holidays. AIM: To examine the need for a 7-day community CNS service. METHOD: Activity data was collected for 6 months and feedback was sought from service users and the CNS team. RESULTS: There were 132 out-of-hours telephone contacts in the 6-month period, generating 35 home visits. Almost two thirds of these calls were proactive, 'planned' contacts. Most unplanned calls (68%) were from a carer for advice about symptom management and support as the patient's condition changed. CONCLUSION: The pilot demonstrated the need for a CNS service 7 days a week, and the service is now embedded in practice. Seven-day working benefits patients and families while being valued by the professional team.

Community health nursing in China: status, challenges, and development strategies.

The article describes the origins and current state of development of community health nursing (CHN) in China, as well as several factors that have shaped its development. CHN began in China in 1997, and the quantity of services has increased greatly in recent years. However, most community nurses report that they merely duplicate the jobs of hospital nurses. Thus, CHN has not developed to its full potential, and the main causes can be attributed to inadequate management and a lack of personnel, funding, and public confidence. Although the Chinese government has implemented several policies to promote its development, Chinese CHN is still in its infancy and many difficulties must be overcome before it can meet the demands of social development.

A necessary change: the transfer of care from hospital to community.

While there is ample evidence for the benefits of diverting resources from hospital delivery out to the community in terms of improved patient safety, very little is known about the impact on a healthcare provider's efficiency and output (Øvretveit, 2009).

Optimising productivity, quality and efficiency in community nursing.

By 2014 the NHS is expected to make £21 billion in efficiency savings and increase productivity by 6% per annum, while maintaining or improving the quality of care. Given that the cost of the 1.7 million strong workforce represents 60% of the NHS budget, changes are likely. This context of innovation and cost-effectiveness has resulted in an ever greater emphasis to fully engage and support community nursing.

Health promotion in nursing and cost-effectiveness.

Close examination of the different healthcare systems and the present economic crisis worldwide suggests that all health organizations should re-evaluate the concept of health promotion and its relationship to cost-effectiveness. When choosing the most efficient and cost-effective system, each nation's healthcare system must seriously start to implement strategies for the change. Health professions, including nursing, must change their vision of education both in academic and practice settings, to focus on health promotion and illness prevention. The key principle underlying this paper is to illustrate the importance of health promotion and cost-effectiveness being adopted by all health organizations worldwide, as well as to observe the experiences of selected counties in developing a health policy related to education in primary healthcare. The paper will include a plan adopted by the General Nursing Directorate (GND) in the Kingdom of Saudi Arabia (SA), which contains a health promotion policy for the nursing administrations in all governmental primary healthcare centers in Saudi Arabia.

Unit cost of Mohs and Dermasurgery Unit.

BACKGROUND: Appropriate pricing for medical services of not-for-profit hospital is necessary. The prices should be fair to the public and should be high enough to cover the operative costs of the organization. OBJECTIVE: The purpose of this study was to determine the cost and unit cost of medical services performed at the Mohs and Dermasurgery Unit (MDU), Department of Dermatology, The University of Texas-MD Anderson Cancer Center, Houston, TX from the healthcare provider's perspective. METHODS: MDU costs were retrieved from the Financial Department for fiscal year 2006. The patients' statistics were acquired from medical records for the same period. Unit cost calculation was based on the official method of hospital accounting. RESULTS: The overall unit cost for each patient visit was $673.99 United States dollar (USD). The detailed unit cost of nurse visit, new patient visit, follow-up visit, consultation, Mohs and non-Mohs procedure were, respectively, $368.27, $580.09, $477.82, $585.52, $1,086.12 and $858.23 USD. With respect to a Mohs visit, the unit cost per lesion and unit cost per stage were $867.89 and $242.30 USD respectively. CONCLUSIONS: Results from this retrospective study provide information that may be used for pricing strategy and resource allocation by the administrative board of MDU.