Andriy Danyliv

Attitudes towards legalising physician provided euthanasia in Britain: The role of religion over time

Hastening the death of another whether through assisted suicide or euthanasia is the subject of intense debate in the UK and elsewhere. In this paper we use a nationally representative survey of public attitudes - the British Social Attitudes survey - to examine changes in attitudes to the legalisation of physician provided euthanasia (PPE) over almost 30 years (1983-2012) and the role of religious beliefs and religiosity in attitudes over time. Compatible questions about attitudes to euthanasia were available in the six years of 1983, 1984, 1989, 1994, 2005, and 2012. We study the trends in the support for legalisation through these time points and the relationship between attitudes, religious denomination and religiosity, controlling for a series of covariates. In total, 8099 individuals provided answers to the question about PPE in the six years of the study. The support for legalisation rose from around 76.95% in 1983 to 83.86% in 2012. This coincided with an increase in secularisation exhibited in the survey: the percentage of people with no religious affiliation increasing from 31% to 45.4% and those who do not attend a religious institution (e.g. church) increasing from 55.7% to 65.03%. The multivariate analysis demonstrates that religious affiliation and religiosity as measured by religious institution attendance frequency are the main contributors to attitudes towards euthanasia, and that the main increase in support happened among the group with least religious affiliation. Other socio-demographic characteristics do not seem to alter these attitudes systematically across the years. Our study demonstrates an increase in the support of euthanasia legalisation in Britain in the last 30 years coincided with increased secularisation. It does not follow, however, that trends in public support are immutable nor that a change in the law would improve on the current pragmatic approach toward hastening death by a physician adopted in England and Wales in terms of the balance between compassion and safeguards against abuse offered.

Short‐ and long‐term effects of gestational diabetes mellitus on healthcare cost: a cross‐sectional comparative study in the ATLANTIC DIP cohort

This paper examines the association between gestational diabetes mellitus and costs of care during pregnancy and 2–5 years post pregnancy.

A Prepregnancy Care Program for Women With Diabetes: Effective and Cost Saving

CONTEXT Only a minority of women with diabetes attend prepregnancy care service and the economic effects of providing this service are unclear. OBJECTIVE The objective of the study was to design, put into practice, and evaluate a regional prepregnancy care program for women with types 1 and 2 diabetes. DESIGN This was a prospective cohort and cost-analysis study. SETTING The study was conducted at antenatal centers along the Irish Atlantic Seaboard. PARTICIPANTS Four hundred fourteen women with type 1 or 2 diabetes participated in the study. INTERVENTIONS The intervention for the study was a newly developed prepregnancy care program. MAIN OUTCOME MEASURES The program was assessed for its effect on the risk of adverse pregnancy outcomes. The difference between program delivery cost and the excess cost of treating adverse outcomes in nonattendees was evaluated. RESULTS In total, 149 (36%) attended: this increased from 19% to 50% after increased recruitment measures in 2010. Attendees were more likely to take preconception folic acid (97.3% vs 57.7%, P < .001) and less likely to smoke (8.7% vs 16.6%, P = .03) or take potentially teratogenic medications at conception (0.7 vs 6.0, P = .008). Attendees had lower glycated hemoglobin levels throughout pregnancy (first trimester glycated hemoglobin 6.8% vs 7.7%, P < .001; third trimester glycated hemoglobin 6.1% vs 6.5%, P = .001), and their offspring had lower rates of serious adverse outcomes (2.4% vs 10.5%, P = .007). The adjusted difference in complication costs between those who received prepregnancy care vs usual antenatal care only is €2578.00. The average cost of prepregnancy care delivery is €449.00 per pregnancy. CONCLUSIONS This regional prepregnancy care program is clinically effective. The cost of program delivery is less than the excess cost of managing adverse pregnancy outcomes.

The cost-effectiveness of screening for gestational diabetes mellitus in primary and secondary care in the Republic of Ireland

Aims/hypothesisThe aim of the study was to assess the cost-effectiveness of screening for gestational diabetes mellitus (GDM) in primary and secondary care settings, compared with a no-screening option, in the Republic of Ireland.MethodsThe analysis was based on a decision-tree model of alternative screening strategies in primary and secondary care settings. It synthesised data generated from a randomised controlled trial (screening uptake) and from the literature. Costs included those relating to GDM screening and treatment, and the care of adverse outcomes. Effects were assessed in terms of quality-adjusted life years (QALYs). The impact of the parameter uncertainty was assessed in a range of sensitivity analyses.ResultsScreening in either setting was found to be superior to no screening, i.e. it provided for QALY gains and cost savings. Screening in secondary care was found to be superior to screening in primary care, providing for modest QALY gains of 0.0006 and a saving of €21.43 per screened case. The conclusion held with high certainty across the range of ceiling ratios from zero to €100,000 per QALY and across a plausible range of input parameters.Conclusions/interpretationThe results of this study demonstrate that implementation of universal screening is cost-effective. This is an argument in favour of introducing a properly designed and funded national programme of screening for GDM, although affordability remains to be assessed. In the current environment, screening for GDM in secondary care settings appears to be the better solution in consideration of cost-effectiveness.

Screening for gestational diabetes mellitus in primary versus secondary care: The clinical outcomes of a randomised controlled trial.

AIMS To examine the clinical outcomes of screening for gestational diabetes mellitus (GDM) in primary care versus secondary care, in the Irish healthcare system. DESIGN AND METHODS A parallel group randomised controlled trial (RCT) of screening for GDM in primary versus secondary care was used to examine (i) prevalence, (ii) gestational week of screen, (iii) time to access specialist care, and (iv) maternal and neonatal outcomes. In total 781 women were recruited for screening in primary care (n=391) or secondary care (n=390). RESULTS The prevalence of GDM and gestational week of screen were similar in both locations. There was a trend towards a longer time to access diabetes care in primary care (24days) versus secondary care (19days), a difference of 5days (p=0.09). Women screened in primary care also showed a trend towards a higher rate of large for gestational age (LGA) infants (20%) than those screened in secondary care (14.7%), (p=0.09). There were no differences between groups in maternal outcomes. CONCLUSIONS This RCT suggests that screening for GDM in secondary care may be associated with potentially faster time to access specialist antenatal diabetes care and possibly lower LGA rates. Further research is needed to clarify these findings and to improve the delay in accessing specialist care requires an urgent focus. Further research is needed to test these findings in other health systems.

Factors influencing lifestyle behaviours during and after a gestational diabetes mellitus pregnancy

Objective: This qualitative study examined the healthy lifestyle behaviours undertaken during and after a pregnancy complicated by gestational diabetes mellitus (GDM) and the factors that influenced the likelihood of undertaking of such behaviours. Methods: Semi-structured telephone interviews were conducted with women who had a pregnancy complicated by GDM in the previous 3–7 years. Interviews were analysed using a theoretical thematic analysis approach. Results: Thirteen women provided interviews as part of this study. Women typically engaged in healthy behaviours in terms of diet, physical activity and glucose monitoring during their GDM pregnancy, but generally these behaviours were not maintained postpartum. Women appear not to be intrinsically motivated to engage in healthy lifestyle behaviours, but rather require the support of an extrinsic motivator such as their unborn child or the support of healthcare professionals. A gap exists between womens knowledge of their increased long-term diabetes risk and the behaviours which they undertake to reduce this risk in the postpartum period. Conclusion: Women with previous GDM need increased support in the postpartum period to assist them to develop self-management and prioritisation skills to take control of their increased type 2 diabetes mellitus risk.

Response to Dr. Coustan: Costs of gestational diabetes (comment on Danyliv, A. et al. Short‐ and long‐term effects of gestational diabetes mellitus on healthcare cost: a cross‐sectional comparative study in the ATLANTIC DIP cohort)

In his letter of 15 June 2015, Professor Coustan raised questions with regards to the diagnostic criteria used in our article assessing the maternal care cost and healthcare cost 2– 5 years after pregnancy associated with gestational diabetes mellitus [1]. As Professor Coustan rightly points out, we used International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria retrospectively to identify the women who would have met these criteria in the original study. In the original Atlantic Diabetes in Pregnancy (ATLANTIC DIP) cohort, pregnant women were identified and offered treatment based on World Health Organization (WHO) 1999 criteria. Thus, the group of women who met IADPSG criteria, but did not meet WHO 1999 criteria would have not been identified and treated originally, which might potentially have had impact on the healthcare utilization in anteand neonatal period. As requested, we present the results of the cost analysis in the four resulting subgroups: (group 1) those who met no criteria and were not identified or treated, (group 2) those who met WHO 1999 criteria only and were identified and treated, (group 3) those who met IADPSG criteria only and were not identified or treated, and (group 4) those who met both sets of criteria and were identified and treated during their pregnancies. As in the original article, we use the same cost aggregates: (1) maternal care cost including childbirth and neonatal care; and (2) cost of health care 2–5 years post pregnancy, including costs related to diabetes care, and those that are not directly related to it (primary care, medical specialists, outpatient day centre visits, hospital services, and non-diabetic medicines). The unadjusted mean costs in the four groups are presented in Table 1. The maternal care and healthcare cost 2–5 years after delivery in groups 2, 3 and 4 are statistically compared with those in group 1. These differences are assessed by applying the generalized linear model (with logarithmic link and gamma distribution family) with a set of covariates as described in the main article. The resulting P-value of the group effect in comparison with the