Cost analysis of care and blood transfusions in patients with Major Obstetric Haemorrhage in Ireland.

BACKGROUND AND OBJECTIVES: Obstetric haemorrhage is the leading cause of maternal morbidity and mortality worldwide. We aimed to estimate the economic cost of Major Obstetric Haemorrhage (MOH) and the cost of therapeutic blood components used in the management of MOH in Ireland. MATERIALS AND METHODS: We performed a nationwide cross-sectional study utilising top-down and bottom-up costing methods on women who experienced MOH during the years 2011-2013. Women with MOH were allocated to Diagnostic Related Groups (DRGs) based on the approach to MOH management (MOH group). The total number of blood components used for MOH treatment and the corresponding costs were recorded. A control group representative of a MOH-free maternity population was designed with predicted costs. All costs were expressed in Euro (€) using 2022 prices and the incremental cost of MOH to maternity costs was calculated. Cost contributions are expressed as percentages from the estimated total cost. RESULTS: A total of 447 MOH cases were suitable for sorting into DRGs. The estimated total cost of managing women who experienced MOH is approximately €3.2 million. The incremental cost of MOH is estimated as €1.87 million. The estimated total cost of blood components used in MOH management was €1.08 million and was based on an estimated total of 3997 products transfused. Red blood cell transfusions accounted for the highest contribution (20.22%) to MOH total cost estimates compared to other blood components. CONCLUSIONS: The total cost of caring for women with MOH in Ireland was approximately €3.2 million with blood component transfusions accounting for between one third and one half of the cost.

A happy home? Socio-economic inequalities in depressive symptoms and the role of housing quality in nine European countries.

BACKGROUND: This study examines the prevalence of and socio-economic inequalities in depressive symptoms in nine high-income European countries, focusing in particular on the role of housing quality. METHODS: Using the European Social Survey, a concentration index of depressive symptoms in each country is estimated. The role of housing quality is assessed by examining the risk factors associated with the concentration index, using the Recentred Influence Function method. To contextualise the housing quality results, other predictors of inequalities in depressive symptoms inequalities are also quantified and discussed. RESULTS: Our results indicate that inequalities in depressive symptoms are concentrated among poorer respondents both in each country and in total. Austria and Belgium have the lowest inequalities and France has the highest. No geographic pattern is evident. Housing problems are associated with higher inequalities in six of the nine countries in the sample. While no association is evident for indicators of socio-economic status such as years of education and income, financial strain is significant. CONCLUSIONS: This study is the first to estimate the degree of socio-economic inequality in depressive symptoms across European countries. The association between poor housing and poorer inequalities suggests that housing has a role to play lowering depressive symptoms inequalities.

Evaluation of the impact and implementation of a national clinical programme for the management of self-harm in hospital emergency departments: study protocol for a natural experiment.

BACKGROUND: A National Clinical Programme for the Management of Hospital-Presenting Self-Harm (NCP-SH) was introduced in Ireland in 2014. This involved the development of a model of care to standardise the management of self-harm in emergency departments, to be delivered by dedicated clinical nurse specialists. The core components of the programme were to: ensure an empathic and timely response, conduct a biopsychosocial assessment, involve family members in assessment and discharge planning, and provide a bridge to next care. The overall aim of the programme was to reduce the rate of repeat self-harm. This multistage study will evaluate the impact of the NCP-SH on hospital-presenting self-harm and to identify determinants influencing its implementation. METHODS: Employing a sequential mixed methods design, the first stage will use data from the National Self-Harm Registry Ireland to examine the impact of the NCP-SH on self-harm repetition, along with other aspects of care, including provision of psychosocial assessments and changes in admissions and postdischarge referrals. A cost-effectiveness analysis will assess the cost per repeat self-harm attendance avoided as a result of the NCP-SH. The second stage will identify the influences of implementation fidelity-adherence to the programme's core components-using a combination of document analysis and semistructured interviews with staff of the programme, guided by the Consolidated Framework for Implementation Research. ETHICS AND DISSEMINATION: This study has received full ethical approval and will run until August 2023. This study is novel in that it will identify important factors influencing successful implementation of complex programmes. It is expected that the findings will provide important learnings for the integration of mental health services in general hospital settings and will be disseminated via peer-review publications along with reports for clinicians and policy-makers.

Assessing direct healthcare costs when restricted to self-reported data: a scoping review.

BACKGROUND: In the absence of electronic health records, analysis of direct healthcare costs often relies on resource utilisation data collected from patient-reported surveys. This scoping review explored the availability, use and methodological details of self-reported healthcare service utilisation and cost data to assess healthcare costs in Ireland. METHODS: Population health surveys were identified from Irish data repositories and details were collated in an inventory to inform the literature search. Irish cost studies published in peer-reviewed and grey sources from 2009 to 2019 were included if they used self-reported data on healthcare utilisation or cost. Two independent researchers extracted studies' details and the PRISMA-ScR guidelines were used for reporting. RESULTS: In total, 27 surveys were identified containing varying details of healthcare utilisation/cost, health status, demographic characteristics and health-related risk and behaviour. Of those surveys, 21 were general population surveys and six were study-specific ad-hoc surveys. Furthermore, 14 cost studies were identified which used retrospective self-reported data on healthcare utilisation or cost from ten of the identified surveys. Nine of these cost studies used ad-hoc surveys and five used data from pre-existing population surveys. Compared to population surveys, ad-hoc surveys contained more detailed information on resource use, albeit with smaller sample sizes. Recall periods ranged from 1 week for frequently used services to 1 year for rarer service use, or longer for once-off costs. A range of perspectives (societal, healthcare and public sector) and costing approaches (bottom-up costing and a mix of top-down and bottom-up) were used. The majority of studies (n = 11) determined unit prices using multiple sources, including national healthcare tariffs, literature and expert views. Moreover, most studies (n = 13) reported limitations concerning data availability, risk of bias and generalisability. Various sampling, data collection and analysis strategies were employed to minimise these. CONCLUSION: Population surveys can aid cost assessments in jurisdictions that lack electronic health records, unique patient identifiers and data interoperability. To increase utilisation, researchers wanting to conduct cost analyses need to be aware of and have access to existing data sources. Future population surveys should be designed to address reported limitations and capture comprehensive health-related, demographic and resource use data.

PARROT Ireland: Placental growth factor in Assessment of women with suspected pre-eclampsia to reduce maternal morbidity: a Stepped Wedge Cluster Randomised Control Trial Research Study Protocol.

INTRODUCTION: Women presenting with suspected pre-eclampsia are currently triaged on the basis of hypertension and dipstick proteinuria. This may result in significant false positive and negative diagnoses resulting in increased morbidity or unnecessary intervention. Recent data suggest that placental growth factor testing may be a useful adjunct in the management of women presenting with preterm pre-eclampsia. The primary objective of this trial is to determine if the addition of placental growth factor testing to the current clinical assessment of women with suspected preterm pre-eclampsia, is beneficial for both mothers and babies. METHODS AND ANALYSIS: This is a multicentre, stepped wedge cluster, randomised trial aiming to recruit 4000 women presenting with symptoms suggestive of preterm pre-eclampsia between 20 and 36+6 weeks' gestation. The intervention of an unblinded point of care test, performed at enrolment, will quantify maternal levels of circulating plasma placental growth factor. The intervention will be rolled out sequentially, based on randomisation, in the seven largest maternity units on the island of Ireland. Primary outcome is a composite outcome of maternal morbidity (derived from the modified fullPIERS model). To ensure we are not reducing maternal morbidity at the expense of earlier delivery and worse neonatal outcomes, we have established a co-primary outcome which will examine the effect of the intervention on neonatal morbidity, assessed using a composite neonatal score. Secondary analyses will examine further clinical outcomes (such as mode of delivery, antenatal detection of growth restriction and use of antihypertensive agents) as well as a health economic analysis, of incorporation of placental growth factor testing into routine care. ETHICS AND DISSEMINATION: Ethical approval has been granted from each of the seven maternity hospitals involved in the trial. The results of the trial will be presented both nationally and internationally at conference and published in an international peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT02881073.

A cost-effectiveness analysis of school-based suicide prevention programmes.

Suicide is one of the leading causes of death among young people globally. In light of emerging evidence supporting the effectiveness of school-based suicide prevention programmes, an analysis of cost-effectiveness is required. We aimed to conduct a full cost-effectiveness analysis (CEA) of the large pan-European school-based RCT, Saving and Empowering Young Lives in Europe (SEYLE). The health outcomes of interest were suicide attempt and severe suicidal ideation with suicide plans. Adopting a payer's perspective, three suicide prevention interventions were modelled with a Control over a 12-month time period. Incremental cost-effectiveness ratios (ICERs) indicate that the Youth Aware of Mental Health (YAM) programme has the lowest incremental cost per 1% point reduction in incident for both outcomes and per quality adjusted life year (QALY) gained versus the Control. The ICERs reported for YAM were €34.83 and €45.42 per 1% point reduction in incident suicide attempt and incident severe suicidal ideation, respectively, and a cost per QALY gained of €47,017 for suicide attempt and €48,216 for severe suicidal ideation. Cost-effectiveness acceptability curves were used to examine uncertainty in the QALY analysis, where cost-effectiveness probabilities were calculated using net monetary benefit analysis incorporating a two-stage bootstrapping technique. For suicide attempt, the probability that YAM was cost-effective at a willingness to pay of €47,000 was 39%. For severe suicidal ideation, the probability that YAM was cost-effective at a willingness to pay of €48,000 was 43%. This CEA supports YAM as the most cost-effective of the SEYLE interventions in preventing both a suicide attempt and severe suicidal ideation.Trial registration number DRKS00000214.

What do women want? Valuing women's preferences and estimating demand for alternative models of maternity care using a discrete choice experiment.

In many countries, there has been a considerable shift towards providing a more woman-centred maternity service, which affords greater consumer choice. Maternity service provision in Ireland is set to follow this trend with policymakers committed to improving maternal choice at hospital level. However, women's preferences for maternity care are unknown, as is the expected demand for new services. In this paper, we used a discrete choice experiment (DCE) to (1) investigate women's strengths of preference for different features of maternity care; (2) predict market uptake for consultant- and midwifery-led care, and a hybrid model of care called the Domiciliary In and Out of Hospital Care scheme; and (3) calculate the welfare change arising from the provision of these services. Women attending antenatal care across two teaching hospitals in Ireland were invited to participate in the study. Women's preferred model of care resembled the hybrid model of care, with considerably more women expected to utilise this service than either consultant- or midwifery-led care. The benefit of providing all three services proved considerably greater than the benefit of providing two or fewer services. From a priority setting perspective, pursuing all three models of care would generate a considerable welfare gain, although the cost-effectiveness of such an approach needs to be considered.

An evaluation of operating room throughput in a stand-alone soft-tissue trauma operating theatre.

BACKGROUND: Operating room time is a limited, expensive commodity in acute hospitals. Strategies aimed at reduction of non-operative time improve operating room throughput and capacity. We conducted a prospective study to evaluate and augment operating room throughput and capacity using context-specific work practice changes. METHODS: Following institutional and ethical approval, an interdisciplinary group designed and introduced a series of work practice changes specific to a stand-alone soft tissue trauma theatre, comprising modifications to patient processing, staff behaviours and additional anaesthesiologist hours. Time intervals relating to each patient were measured during a 16 week period before and after implementing work practice changes. The primary outcome measure was non-operative time, with daily caseload and cancellations amongst secondary outcome measures. RESULTS: 251 procedures were included over 58 working days (8 to 17 Monday to Friday). Non-operative time [55.6 (31.1) vs 52.3 (9.8) minutes, p = 0.48], daily caseload [4 [1-9] vs 4 [2-7], p = 0.56], and the number of daily cancellations [3 [0-11] vs 5 [0-8], p = 0.38], did not differ between baseline and study phases. Regional anaesthesia for upper limb surgery increased during the study phase [26/59 (44.0%) vs 10/63 (15.9%), p = 0.014] with resultant decrease in mean duration of recovery room stay [20.7 (17.7) vs 30 (20.5) minutes, p = 0.0001] and increased recovery room bypass [26/116 (22.4%) vs 6/135 (4.4%), p = 0.0002]. Avoidable delays accounted for 124.8 (72.2) minutes of theatre time lost each day. CONCLUSION: In conclusion, additional attending anaesthesiologist hours combined with work practice changes did not impact on measures of theatre throughput and capacity. The study identified important variables that contribute to avoidable delays, and points the way for future research.

A Cost-Benefit Analysis of Two Alternative Models of Maternity Care in Ireland.

BACKGROUND: The Irish government has committed to expand midwifery-led care alongside consultant-led care nationally, although very little is known about the potential net benefits of this reconfiguration. OBJECTIVES: To formally compare the costs and benefits of the major models of care in Ireland, with a view to informing priority setting using the contingent valuation technique and cost-benefit analysis. METHODS: A marginal payment scale willingness-to-pay question was adopted from an ex ante perspective. 450 pregnant women were invited to participate in the study. Cost estimates were collected primarily, describing the average cost of a package of care. Net benefit estimates were calculated over a 1-year cycle using a third-party payer perspective. RESULTS: To avoid midwifery-led care, women were willing to pay €821.13 (95% CI 761.66-1150.41); to avoid consultant-led care, women were willing to pay €795.06 (95% CI 695.51-921.15). The average cost of a package of consultant- and midwifery-led care was €1,762.12 (95% CI 1496.73-2027.51) and €1018.47 (95% CI 916.61-1120.33), respectively. Midwifery-led care ranked as the best use of resources, generating a net benefit of €1491.22 (95% CI 989.35-1991.93), compared with €123.23 (95% CI -376.58 to 621.42) for consultant-led care. CONCLUSIONS: While both models of care are cost-beneficial, the decision to provide both alternatives may be constrained by resource issues. If only one alternative can be implemented then midwifery-led care should be undertaken for low-risk women, leaving consultant-led care for high-risk women. However, pursuing one alternative contradicts a key objective of government policy, which seeks to improve maternal choice. Ideally, multiple alternatives should be pursued.

What women want: Exploring pregnant women's preferences for alternative models of maternity care.

Depending on obstetric risk, maternity care may be provided in one of two locations at hospital level: a consultant-led unit (CLU) or a midwifery-led unit (MLU). Care in a MLU is sparsely provided in Ireland, comprising as few as two units out of a total 21 maternity units. Given its potential for greater efficiencies of care and cost-savings for the state, there has been an increased interest to expand MLUs in Ireland. Yet, very little is known about women's preferences for midwifery-led care, and whether they would utilise this service when presented with the choice of delivering in a CLU or MLU. This study seeks to involve women in the future planning of maternity care by investigating their preferences for care and subsequent motivations when choosing place of birth. Qualitative research is undertaken to explore maternal preferences for these different models of care. Women only revealed a preference for the MLU when co-located with a CLU due to its close proximity to medical services. However, the results suggest women do not have a clear preference for either model of care, but rather a hybrid model of care which encompasses features of both consultant- and midwifery-led care.

Day care versus inpatient management of nausea and vomiting of pregnancy: cost utility analysis of a randomised controlled trial.

OBJECTIVE: To assess the comparative cost effectiveness of day care over inpatient management of nausea and vomiting of pregnancy (NVP). STUDY DESIGN: A cost utility analysis was performed using a decision analytical model in which a Markov model was constructed. The Markov model was primarily populated with data from a recently published randomised controlled trial. Which included pregnant women presenting to Cork University Maternity Hospital, a tertiary referral maternity hospital, seeking treatment for NVP. Costs and outcomes were estimated from the perspective of the Irish health service (HSE) and patients. A probabilistic sensitivity analysis, using a Monte Carlo simulation, was also performed. A Bayesian Value of Information analysis was used to estimate the value of collecting additional information. RESULTS: When both the healthcare provider and patient's perspective was considered, day care management of NVP remained less costly (mean €985; 95% C.I. 705-1456 vs. €3837 (2124-8466)) and more effective (9.42; 4.19-12.25 vs. 9.49; 4.32-12.39 quality adjusted life years) compared with inpatient management. The Cost Effectiveness Acceptability Curve indicates the probability that day care management is 70% more cost effective compared to inpatient management at a ceiling ratio of €45,000 per QALY, indicating little decision uncertainty. The Bayesian Value of Information analysis indicates there is value in collecting further information; the Expected Value of Perfect Information (EVPI) is estimated to be €5.4 million. CONCLUSION: Day care management of NVP is cost effective compared to inpatient management.

Day care compared with inpatient management of nausea and vomiting of pregnancy: a randomized controlled trial.

OBJECTIVE: To examine day care treatment of nausea and vomiting of pregnancy compared with the traditional inpatient management of this condition. METHODS: We conducted an open-label, single-center, randomized controlled trial to examine the differences between day care and inpatient management of pregnant women with nausea and vomiting of pregnancy. Primary outcome was total number of inpatient nights related to nausea and vomiting of pregnancy. RESULTS: Ninety-eight women were randomized to initial day care management (n=42) or inpatient management (n=56). Results are calculated from the time of randomization until resolution of nausea and vomiting of pregnancy. Women randomized to inpatient care experienced a median (interquartile range) of 2 (1-4) inpatient days compared with 0 (0-2) inpatient days for women randomized to day care (P<.001). Women randomized to initial treatment as an inpatient had significantly more median total number of inpatient admissions (one [1-2] compared with zero [0-1] admissions; P<.001) compared with women randomized to day care. No significant differences were observed in day care visits (median [interquartile range] one [1-4] compared with two [1-4]; P=.30). Women randomized to inpatient care were as satisfied with their care as those randomized to day care (median [interquartile range]: 67 [57-69] compared with 63 [58-71] Client Satisfaction Questionnaire score; P=.7). CONCLUSION: Day care treatment of nausea and vomiting of pregnancy reduced hospital inpatient stay and was acceptable to patients. CLINICAL TRIAL REGISTRATION: ISRCTN Register, http://www.isrctn.org, ISRCTN05023126. LEVEL OF EVIDENCE: : I.

Malaria prevention in north-eastern Tanzania: patterns of expenditure and determinants of demand at the household level.

OBJECTIVE: This study aims to provide a better understanding of the amounts spent on different malaria prevention products and the determinants of these expenditures. METHODS: 1,601 households were interviewed about their expenditure on malaria mosquito nets in the past five years, net re-treatments in the past six months and other expenditures prevention in the past two weeks. Simple random sampling was used to select villages and streets while convenience sampling was used to select households. Expenditure was compared across bed nets, aerosols, coils, indoor spraying, using smoke, drinking herbs and cleaning outside environment. FINDINGS: 68% of households owned at least one bed net and 27% had treated their nets in the past six months. 29% were unable to afford a net. Every fortnight, households spent an average of US $0.18 on nets and their treatment, constituting about 47% of total prevention expenditure. Sprays, repellents and coils made up 50% of total fortnightly expenditure (US$0.21). Factors positively related to expenditure were household wealth, years of education of household head, household head being married and rainy season. Poor quality roads and living in a rural area had a negative impact on expenditure. CONCLUSION: Expenditure on bed nets and on alternative malaria prevention products was comparable. Poor households living in rural areas spend significantly less on all forms of malaria prevention compared to their richer counterparts. Breaking the cycle between malaria and poverty is one of the biggest challenges facing malaria control programmes in Africa.

Determinants of provider choice for malaria treatment: experiences from The Gambia.

Malaria is responsible for an estimated one million deaths per year, the vast majority in sub-Saharan Africa. Many of these deaths are attributed to delays in seeking treatment and poor adherence to drug regimes. While there are a growing number of studies describing the factors influencing treatment seeking for malaria, far less is known about the relative weight given to these factors in different settings. This study estimates two models of demand for malaria treatment in the Farafenni region of The Gambia. The first examines the determinants of seeking malaria treatment outside the home versus no treatment or self-care while the second identifies the determinants of provider choice conditional on having decided to seek malaria treatment outside the home. Providers included hospital; health centre; and 'other' which included pharmacies, kiosks; petty traders; neighbours; and traditional healers. Results show that older people were more likely to opt for self-care, or no treatment. The longer the time spent ill or the more severe the fever, the more likely a treatment was sought outside the home. Time of the year and availability of community infrastructure played a key role in both models. Poorer households and those from the Fula ethnic group were much more likely to visit an 'other' provider than a hospital. The policy and methodological implications of these findings are discussed.

Determinants of bed net use in the Gambia: implications for malaria control.

Malaria is still one of the biggest health threats in the developing world, with an estimated 300 million episodes per year and one million deaths, most of which are in sub-Saharan Africa. Although the efficacy and cost-effectiveness of treated bed nets has been widely reported, little is known about the range, strength, or interaction between different factors that influence their demand at the household level. This study modeled the determinants of bed net ownership as well as the factors that influence the number of bed nets purchased. Data was collected from 1,700 randomly selected households in the Farafenni region of The Gambia. Interviews were also held with 129 community spokespersons to explore the extent to which community level factors such as the quality of roads and access to market centers also influence demand for bed nets. The results of each model of demand and their policy implications are discussed.