Systematic review of international evidence on the effectiveness and costs of paediatric home care for children and young people who are ill.

Promoting 'care closer to home' for ill children is a policy and practice objective internationally. Progress towards this goal is hampered by a perceived lack of evidence on effectiveness and costs. The aim of the work reported here was to establish the strength of current international evidence on the effectiveness and costs of paediatric home care by updating and extending an earlier systematic review. A systematic review following Centre for Reviews and Dissemination guidelines involved updating electronic searches, and extending them to cover paediatric home care for short-term acute conditions. Twenty-one databases were searched from 1990 to April 2007. Hand searching was also carried out. Pairs of team members, guided by an algorithm, selected randomized controlled trials (RCTs), other comparative studies and studies including health economics data. A third reviewer resolved any disagreements. The quality of RCTs was assessed, but a 'best-evidence' approach was taken overall. Data were extracted into specifically designed spreadsheets and a second team member checked all data. Narrative synthesis was used throughout. This paper reports findings from RCTs and studies with health economics data. In total, 16 570 publications were identified after de-duplication. Eleven new RCTs (reported in 17 papers) and 20 papers with health economics data were included and reviewed. Evidence on costs and effectiveness of paediatric home care has not grown substantially since the previous review, but this updated review adds weight to the conclusion that it can deliver equivalent clinical outcomes for children and not impose a greater burden on families. Indeed, in some cases, there is evidence of reduced burden and costs for families compared with hospital care. There is also growing evidence, albeit based on weaker evidence, that paediatric home care may reduce costs for health services, particularly for children with complex and long-term needs.

Evaluation of the implementation of the alert issued by the UK National Patient Safety Agency on the storage and handling of potassium chloride concentrate solution.

OBJECTIVES: To assess the effectiveness of the response of NHS hospital trusts to an alert issued by the National Patient Safety Agency designed to limit the availability of concentrated potassium chloride in hospitals in England and Wales, and to determine the nature of any unintended consequences. DESIGN: Multi-method study involving interviews and a physical inspection of clinical areas. SETTING: 207 clinical areas in 20 randomly selected acute NHS trusts in England and Wales between 31 October 2002 and 31 January 2003. PARTICIPANTS: Senior managers and ward based medical and nursing staff. MAIN OUTCOME MEASURES: Degree of staff awareness of and compliance with the requirements of the national alert, withdrawal of concentrated potassium chloride solutions from non-critical areas, provision of pre-diluted alternatives, storage and recording in accordance with controlled drug legislation. RESULTS: All trusts required that potassium chloride concentrate be stored in a separate locked cup-board from common injectable diluents (100% compliance). Unauthorized stocks of potassium chloride were found in five clinical areas not authorized by the trust (98% compliance). All trusts required documentation control of potassium chloride concentrate in clinical areas, but errors were recorded in 20 of the 207 clinical areas visited (90% compliance). Of those interviewed, 78% of nurses and 30% of junior doctors were aware of the alert. CONCLUSIONS: The NPSA alert was effective and resulted in rapid development and implementation of local policies to reduce the availability of concentrated potassium chloride solutions. The success is likely to be partly due to the nature of the proposed changes and it cannot be assumed that future alerts will be equally effective. Continued vigilance will be necessary to help sustain the changes.

Detection and treatment of psychiatric illness in a general medical ward: a modified cost-benefit analysis.

This article describes a prospective, randomized, controlled trial of screening and treatment for psychiatric disorder in medical in-patients. The study has assessed whether increased recognition of psychiatric disorder among medical in-patients improves clinical outcome and reduces the costs of care, and whether routine involvement of a psychiatrist in the assessment and care of medical in-patients with probable psychiatric disorder is superior to the efforts of the physicians alone. A total of 218 medical in-patients who scored over the screening threshold for psychiatric disorder on the General Health Questionnaire were randomly allocated to one of two intervention groups or a control group. Six months later their mental health, subjective health status, quality of life, and costs of care was reassessed. Mental health and quality of life at 6 months were similar in the two intervention groups and the control group. Patients whose physicians were told the results of the screening test had lower costs for subsequent admissions, but this was probably due to differences between the groups in terms of employment status. Treatments recommended by psychiatrists broke down when patients were discharged home, leading to inadequate treatment of psychiatric disorders. We have not been able to show that routine screening for psychiatric disorder produces any benefit, either in better outcome for patients or reduced costs for the NHS. Further research should: consider examining a more homogeneous group in terms of costs of care; screen only for disorders likely to respond to a specific treatment; and ensure that treatment recommendations are carried out.

The care of patients with chronic schizophrenia: a comparison between two services.

BACKGROUND: There has been a widespread development of community multi-disciplinary teams aimed to deliver coordinated comprehensive mental health care, yet there is little published evidence on the quality of care and economics of providing such care for people with severe mental illness. METHOD: This is a clustered randomized controlled economic comparison of the quality of care for patients with chronic schizophrenia by a multi-disciplinary community team with close links with primary care, and a traditional psychiatric service in a district general hospital psychiatric unit. RESULTS: Two years after it was established, patients with access to the community team had more of their needs met; they had fewer unmet needs; and they were more satisfied with the care they had received. They had more service contacts and received more interventions. The community team resulted in savings in the use of some hospital resources but these were not sufficient to offset the cost of the new service. The community team successfully directed care to patients with more needs, whereas no such relationship was evident for the traditional hospital-based service. Four years after the team was established, it met a greater proportion of needs for underactivity, daily living skills, use of public amenities and managing finances. CONCLUSIONS: Better quality care was provided at 2 and 4 years after its establishment by the multi-disciplinary community service than the traditional hospital-based service. Resources were targeted more efficiently by the community service.

Conceptual framework for clinical and general management.

The UK has more than five years experience of the introduction of patient based management information systems into acute hospitals. These systems support the measurement of activity, process of care and cost of care allowing linkage of management processes of the hospital to direct treatment and care of individual patients. An implicit 'product' model for acute hospital care underlies these systems. When considering the management information needs of community health providers, the limitations of this model became apparent and highlighted the need for a more general model. The paper suggests such a model, not only appropriate for community care but also a better model for hospital services.

Some aspects of family interventions in schizophrenia. II: Financial considerations.

The direct costs to the mental health services for patients who participated in a trial of a behavioural family intervention to reduce schizophrenic relapse were estimated. Comparisons were made between two patient groups from households of high expressed emotion (HEE): one group received a nine-month family intervention (HEE Intervention) and the other group routine treatment (HEE Control). A third group consisted of patients from low-EE households (LEE Control). The significant decrease in relapse rates in the HEE Intervention group compared with the HEE Control group has previously been reported; the analysis of costs indicates that any increase in costs due to the family intervention is outweighed by a decrease in usage of the established mental health services. The intervention resulted in a decrease of 27% in mean cost per patient.

The use of QALYS (quality-adjusted life years) in health service planning.

There has been substantial interest in recent years, among research workers and in health service management, in the potential use of quality-adjusted life years (QALYs) as an aid to decision-making about the development of services and use of resources in health services (Gudex, 1986; Drummond, 1986). In 1986 the North Western Regional Health Authority (RHA) initiated the first large-scale attempt to use QALYs as a practical aid to planning in the National Health Service. This paper draws on the experience of the North Western RHA in examining some methodological and practical issues relating to the future of QALYs as an aid to decision-making in the Health Service.

The evaluation of a hostel ward. A controlled study using modified cost-benefit analysis.

A controlled modified cost-benefit evaluation of a hostel ward caring for new long-stay patients is described and results are presented for the first two years. In some respects the residents of the hostel ward had fewer psychotic impairments than those remaining on the wards of the district general hospital, mainly because the latter seem to continue to acquire such defects, while the former have remained relatively unchanged. The hostel ward residents also develop superior domestic skills, use more facilities in the community, and are more likely to be engaged in constructive activities than controls. These advantages were not purchased at a price, since the cost of providing this form of care for these patients has cost less than care provided by the district general hospital.

Assessing the benefits of psychotherapy: the economic approach.

Recent debate about the place of psychotherapy in the National Health Service, while emphasising the importance of economic evaluation, has concentrated almost exclusively on issues of clinical outcome. This paper argues that the debate has focussed on too narrow a definition of psychotherapy and too limited a view of the possible effects of psychotherapy, both good and bad. It reviews evidence concerning the demand and need for psychotherapy services in a number of clinical settings, and discusses the economic implications of the provision of such services. Economic studies of psychotherapy are reviewed and a conclusion drawn that it might be possible to justify the provision of psychotherapy services on economic grounds, but that considerably more research needs to be done in this area. The directions such future research might take are outlined.

Costing new services: long-term domiciliary oxygen therapy.

An economic appraisal of different methods of long-term treatment with oxygen in the home has shown that the oxygen concentrator is the cheapest and most convenient one. The only method at present generally available in the National Health Service, the use of small oxygen cylinders, is the most expensive and least convenient of those studied. There is need for a more flexible administrative system which will allow patients and the Health Service to benefit from the economies which are offered by technical advances.