Randomized controlled trial and economic evaluation of nurse-led group support for young mothers during pregnancy and the first year postpartum versus usual care.

BACKGROUND: Child maltreatment is a significant public health problem. Group Family Nurse Partnership (gFNP) is a new intervention for young, expectant mothers implemented successfully in pilot studies. This study was designed to determine the effectiveness and cost-effectiveness of gFNP in reducing risk factors for maltreatment with a potentially vulnerable population. METHODS: A multi-site, randomized controlled, parallel-arm trial and prospective economic evaluation was conducted, with allocation via remote randomization (minimization by site, maternal age group) to gFNP or usual care. Participants were expectant mothers aged below 20 years with at least one live birth, or aged 20-24 years with no live births and with low educational qualifications. Data from maternal interviews at baseline and when infants were 2, 6 and 12 months, and video-recording at 12 months, were collected by researchers blind to allocation. Cost information came from weekly logs completed by gFNP family nurses and other service delivery data reported by participants. Primary outcomes measured at 12 months were parenting attitudes (Adult-Adolescent Parenting Index, AAPI-2) and maternal sensitivity (CARE Index). The economic evaluation was conducted from a UK NHS and personal social services perspective with cost-effectiveness expressed in terms of incremental cost per quality-adjusted life year (QALY) gained. The main analyses were intention-to-treat with additional complier average causal effects (CACE) analyses. RESULTS: Between August 2013 and September 2014, 492 names of potential participants were received of whom 319 were eligible and 166 agreed to take part, 99 randomly assigned to receive gFNP and 67 to usual care. There were no between-arm differences in AAPI-2 total (7 · 5/10 in both, SE 0.1), difference adjusted for baseline, site and maternal age group 0 · 06 (95% CI - 0 · 15 to 0 · 28, p = 0 · 59) or CARE Index (intervention 4 · 0 (SE 0 · 3); control 4 · 7 (SE 0 · 4); difference adjusted for site and maternal age group - 0 · 68 (95% CI - 1 · 62 to 0 · 16, p = 0 · 25) scores. The probability that gFNP is cost-effective based on the QALY measure did not exceed 3%. CONCLUSIONS: The trial did not support gFNP as a means of reducing the risk of child maltreatment in this population but slow recruitment adversely affected group size and consequently delivery of the intervention. TRIAL REGISTRATION: ISRCTN78814904 . Registered on 17 May 2013.

The Cost-effectiveness Analysis of Nurse-Family Partnership in the United States.

We evaluated whether Nurse-Family Partnership might serve as a cost-effective social policy for improving health. Using data from studies of randomized controlled trials as well as real-world data, we conducted a Monte Carlo simulation to estimate cost-effectiveness of Nurse-Family Partnership in a hypothetical cohort of first-born children in the United States. Analyses were conducted in 2015. Were all new mothers eligible for Nurse-Family Partnership, the program would produce 0.11 QALYs (95% confidence interval [CI]=0.06, 0.17) at an additional cost of $1,021 (95% CI=-$2,831, $4,414) per nurse-visited child's lifetime relative to the comparison-group children or $14,642 (95% CI = Savings, $71,877) per QALY gained. However, if applied to high-risk mothers, it would generate 0.19 QALYs (95% CI = 0.09, 0.44) and a net benefit of $2,764 (95% CI =-$1,210, $7,092) per nurse-visited child. Nurse-Family Partnership should be considered as a policy investment, particularly in an era of investments in the social determinants of health.

Cost-effectiveness of the Family Nurse Partnership (FNP) programme in England: Evidence from the building blocks trial.

RATIONAL, AIMS, AND OBJECTIVES: The Family Nurse Partnership (FNP) is a licensed intensive home visiting intervention developed in the United States. It has been provided in England by the Department of Health since 2006. The Building Blocks trial assessed the effectiveness and cost-effectiveness of FNP in England. METHODS: We performed a cost-utility analysis (National Health Service (NHS) perspective) alongside the Building Blocks trial (over 2.5 y). The analysis was conducted in accordance with National Institute for Health and Clinical Excellence (NICE) reference case standards. Health-related quality of life was elicited from mothers using the EQ-5D-3L. Resource-use data were collected from self-reported questionnaires, Hospital Episode Statistics, general practitioner records and the central Department of Health FNP database. Costs and quality-adjusted life years (QALYs) were discounted at 3.5%. The base case analysis used an intention to treat approach on the imputed dataset using multiple imputation. RESULTS: The FNP intervention costs on average £1812 more per participant compared to usual care (95% confidence interval: -£2700; £5744). Incremental adjusted mean QALYs are marginally higher for FNP (mean difference 0.0036, 95% confidence interval: -0.017; 0.025). The probability of FNP being cost-effective is less than 20% given the current NICE willingness to pay threshold of £20 000 per additional QALY. The results were robust to sensitivity analyses. CONCLUSION: Given the absence of significant benefits of FNP in terms of the primary outcomes of the trial and only marginal maternal QALY gains, FNP does not represent a cost-effective intervention when compared with existing services already offered to young pregnant women.

[Analysis of a Family-centred Care Programme with Follow-up Home-visits in Neonatology - In Times of the Directive from G-BA]. / Konzeptanalyse einer stationären und ambulanten psychosozialen familienzentrierten Betreuung in der Neonatologie in Zeiten des G-BA-Beschlusses.

BACKGROUND: Marked progress in neonatology changed care of very preterm infants (VLBW) over the last decades - but also the attitude towards family-centred care (FCC). With the directive of the German Federal Joined Committee (G-BA), politicians recognize the necessity of neonatal FCC. AIM: To evaluate time and personnel costs necessary at a centre of established FCC. METHODS: Elternberatung "Frühstart" is a FCC programme for VLBW and seriously ill neonates from preganancy at risk to follow-up home-visits delivered by one interdisciplinary team. Analysis (2011-2014): 1.) Number of cases /participation in programme, 2.) resources of time, 3) and personnel, 4.) funding, 5) economic impact. RESULTS: 1.1.2011-31.12.2014: 441 cases (total cases: 2 212) participated in the programme. Participation of VLBW: mean 92% (86.4-97,2%). Costs of time are highest in neonates with congenital malformations: median 13.8 h, VLBW: median 11,2 h. Transition to home is most time intensive: median 7,3 (0-42.5) h. In average of 3.1 full-time nurses (part-time workers) are able to counsel 48 families/quarter. In severe cases funding is partly provided by health care insurances for social medical aftercare: positive applications: mean 92.7% (79.6-97.7%). CONCLUSION: Participation in the FCC programme in neonatology is high and costs of time are manageable.

Nurse Family Partnership: Comparing Costs per Family in Randomized Trials Versus Scale-Up.

The literature that addresses cost differences between randomized trials and full-scale replications is quite sparse. This paper examines how costs differed among three randomized trials and six statewide scale-ups of nurse family partnership (NFP) intensive home visitation to low income first-time mothers. A literature review provided data on pertinent trials. At our request, six well-established programs reported their total expenditures. We adjusted the costs to national prices based on mean hourly wages for registered nurses and then inflated them to 2010 dollars. A centralized data system provided utilization. Replications had fewer home visits per family than trials (25 vs. 31, p = .05), lower costs per client ($8860 vs. $12,398, p = .01), and lower costs per visit ($354 vs. $400, p = .30). Sample size limited the significance of these differences. In this type of labor intensive program, costs probably were lower in scale-up than in randomized trials. Key cost drivers were attrition and the stable caseload size possible in an ongoing program. Our estimates reveal a wide variation in cost per visit across six state programs, which suggests that those planning replications should not expect a simple rule to guide cost estimations for scale-ups. Nevertheless, NFP replications probably achieved some economies of scale.

Community intervention to prevent child maltreatment in England: evaluating the contribution of the Family Nurse Partnership.

BACKGROUND: The Government in England has recognized the importance of early intervention to promote positive child development and prevent maltreatment. In doing so, efforts have been made to increase the implementation of the Family Nurse Partnership (FNP) to target a greater number of families who require intensive secondary intervention. METHODS: This paper presents an argument that the FNP can be targeted more effectively to yield a greater return on investment. This is based on the re-analysis of data collected by the largest cohort study carried out into risk factors for child maltreatment in England. RESULTS: Currently, around 315 health visitors are estimated to be implementing this programme, projected to increase to around 585 health visitors in 2015. However, targeting the programme towards first-time, young vulnerable mothers with low socio-economic status means that around 1350 health visitors would be needed. Critically, targeting only this population is estimated to prevent only 10% of cases of child abuse and neglect. CONCLUSIONS: By targeting risk factors which are less common in the general population but which are more prevalent amongst abusive families, fewer specialist health visitors would be needed to prevent a higher percentage of child maltreatment.

Establishment of a family-centred care programme with follow-up home visits: implications for clinical care and economic characteristics.

BACKGROUND: Elternberatung Frühstart is a family-centred care programme for very preterm infants and seriously ill neonates and their parents. The uniqueness of this programme is in its consistency and continuity in parental counselling from pregnancy at risk to follow-up home visits. PATIENTS AND METHODS: Family-centred care is provided by specialised nurses, a social education worker, a case manager, a psychologist and neonatologists. They give support and information to parents and facilitate transition to home including co-ordination of health care services and support networks. The programme starts with information for parents at risk of preterm delivery to lessen their anxieties and worries. After birth, parental bonding is encouraged and parents are involved in daily care procedures. The following weeks focus on communication, information and education in order to enhance parental competence. Discharge planning and coordinated follow-up visits involve the family doctor and several members of the welfare and health care system. One of the key objectives is to prevent re-hospitalisation. Over a 4 year period 330 families participated. Funding is provided by: 1) the hospital, from admission to discharge equivalent to one full-time nursing staff, 2) charity donations for follow-up visits and 3) health care insurance for social medical aftercare (Bunter Kreis) following §43, 2 SGB V in severe cases. RESULTS: As a result of this programme, the median length of stay was reduced by 24 days; the number of patients that stayed longer than average were reduced by 64% in the group of patients born < 1 500 g. At the same time the patient throughput increased from 243 to 413. CONCLUSION: To conclude, a family-centred care programme with coordinated follow-up increases parental satisfaction, reduces the length of the hospital stay and is therefore profitable.

El valor social de los cuidados informales provistos a personas mayores en situación de dependencia en España / The social value of informal care provided to elderly dependent people in Spain

Objetivo: El objetivo de este trabajo es analizar una parte del beneficio social que proporcionan los cuidados no profesionales (informales), planteando el escenario hipotético de los recursos que habría que movilizar si hubiera que sustituir su labor. Métodos y datos: Empleando información de la Encuesta sobre Discapacidades, Autonomía personal y situaciones de Dependencia 2008 (EDAD-08) se ha realizado un ejercicio de simulación sobre el coste que tendría que asumir la sociedad si reemplazara los cuidados informales a personas de 65 y más años de edad por servicios sociales profesionales. Para tal fin se estiman las horas de cuidados informales prestadas en España durante el año 2008 y se valoran monetariamente mediante el método de coste de sustitución. Resultados: La traducción monetaria de las horas de cuidados informales prestados durante el año 2008 nos lleva a cifras que oscilan entre los 25.000 y los 40.000 millones de euros, dependiendo del precio sombra asignado a la hora de cuidado. Estas cifran serían equivalentes a entre un 2,3% y un 3,8% del producto interior bruto (PIB) del mismo año. Cuando nos trasladamos al ámbito regional, la valoración oscila de manera muy importante entre comunidades autónomas, llegando alguna a alcanzar cifras que equivalen a cerca de un 6% de su PIB. Conclusiones: El abordaje integral de los cuidados de las personas dependientes exige incluir el papel y la atención a las necesidades de las personas cuidadoras y avanzar en su reconocimiento social (AU)

Objective: To analyze one part of the social benefit derived from non-professional (informal) caregivers by analyzing the hypothetical amount of resources that would need to be invested if informal care were substituted by formal care. Methods and data: Using data from the Survey of Disabilities, Personal Autonomy and Situations of Dependency (EDAD-2008), we estimated the cost to society if informal care were substituted by formal care of the population aged 65 years and older. For this purpose, first we computed the total amount of informal caregiving hours provided in Spain in 2008, and then we obtained its monetary worth by using the proxy good method. Results: The monetary worth of informal care provided in 2008 ranged from 25,000 and 40,000 million euros, depending on the shadow price used to value one hour of care. These figures represented between 2.3% and 3.8% of the GDP for the same year. In regional terms, the valuation of informal care across Spain's autonomous regions showed a significant degree of dispersion, and in some regions, amounted to 6% of their GDP. Conclusions: The comprehensive approach to the care of the elderly should take the role and needs of informal caregivers into consideration. Caregivers should be given greater social recognition (AU)

A nursing pilot study on bedside reporting to promote best practice and patient/family-centered care.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of bedside nursing report implementation on a pediatric neuroscience unit. BACKGROUND: The change-of-shift nursing report often involves only nurse-to-nurse communication, occurs far away from the patient's bedside, and includes little or no patient/family involvement. Studies show that the bedside nursing report is a more comprehensive and patient-centered approach (C. D. Anderson & R. R. Mangino, 2006). METHODS: Patient and nurse satisfaction and nursing overtime were measured 6 months before and 6 months after the implementation of bedside reporting. Data were analyzed using paired t test, chi-square test, and Fisher's exact tests to determine significant changes. RESULTS: Patients, families, and nurses reported an increase in satisfaction after the implementation of bedside reporting. Overtime decreased and represented a potential cost savings of nearly $13,000 annually. CONCLUSIONS: Bedside reporting saves money, improves patient and nurse satisfaction, and is a more comprehensive approach to change-of-shift reporting.

Les dispositions financières et structurelles pour l`infirmière de famille

Il presente le rapport sur une réunion de l'OMS sur la notion d'infirmière de famille, les mécanismes permettant le financement et la mise en place, les moyens d’adopter la notion d’infirmière de famille dans différents systèmes de soins, l'évaluation des implications, et les dispositions financières et structurelles nécessaires. Aussi il présente les recommandations sur la base des discussions des groupes de travail et des trois modèles de systèmes de soins examinés. Document en PDF. Acrobat Reader requis