Aoife Brick

Evidence on the cost and cost-effectiveness of palliative care: A literature review

Background: In the context of limited resources, evidence on costs and cost-effectiveness of alternative methods of delivering health-care services is increasingly important to facilitate appropriate resource allocation. Palliative care services have been expanding worldwide with the aim of improving the experience of patients with terminal illness at the end of life through better symptom control, coordination of care and improved communication between professionals and the patient and family. Aim: To present results from a comprehensive literature review of available international evidence on the costs and cost-effectiveness of palliative care interventions in any setting (e.g. hospital-based, home-based and hospice care) over the period 2002–2011. Design: Key bibliographic and review databases were searched. Quality of retrieved papers was assessed against a set of 31 indicators developed for this review. Data Sources: PubMed, EURONHEED, the Applied Social Sciences Index and the Cochrane library of databases. Results: A total of 46 papers met the criteria for inclusion in the review, examining the cost and/or utilisation implications of a palliative care intervention with some form of comparator. The main focus of these studies was on direct costs with little focus on informal care or out-of-pocket costs. The overall quality of the studies is mixed, although a number of cohort studies do undertake multivariate regression analysis. Conclusion: Despite wide variation in study type, characteristic and study quality, there are consistent patterns in the results. Palliative care is most frequently found to be less costly relative to comparator groups, and in most cases, the difference in cost is statistically significant.

Explaining the increase in breastfeeding at hospital discharge in Ireland, 2004–2010

BackgroundDespite a steady increase in the rate of breastfeeding in Ireland over the period 2004–2010 (from 46.8xa0% in 2004 to 55.7xa0% in 2010), Irish rates of breastfeeding are still low by international standards. Over this period, the characteristics of mothers and babies changed, with mothers increasingly older, having fewer children and increasingly born outside the Republic of Ireland.AimsThe purpose of this paper is to understand the extent to which changing maternal and birth characteristics explained the increase in the breastfeeding rate in Ireland over the period 2004–2010.MethodsWe apply non-linear decomposition techniques to micro-data from the 2004–2010 Irish National Perinatal Reporting System to examine this issue. The technique allows us to quantify the extent to which the increase in the breastfeeding rate over the period 2004–2010 is due to changing maternal and birth characteristics.ResultsWe find that between 55 and 74xa0% of the increase over the period can be explained by changing characteristics, with the increasing share of mothers from Eastern Europe, and increasing maternal age the most important contributors.ConclusionsThese findings suggest that the existing policy initiatives have been relatively ineffective in increasing breastfeeding rates in Ireland, i.e. most of the observed increase occurred simply because the characteristics of mothers were changing in ways that made them increasingly likely to breastfeed.

National Variation in Caesarean Section Rates: A Cross Sectional Study in Ireland

Objective Internationally, caesarean section (CS) rates are rising. However, mean rates of CS across providers obscure extremes of CS provision. We aimed to quantify variation between all maternity units in Ireland. Methods Two national databases, the National Perinatal Reporting System and the Hospital Inpatient Enquiry Scheme, were used to analyse data for all women delivering singleton births weighing ≥500g. We used multilevel models to examine variation between hospitals in Ireland for elective and emergency CS, adjusted for individual level sociodemographic, clinical and organisational variables. Analyses were subsequently stratified for nullipara and multipara with and without prior CS. Results The national CS rate was 25.6% (range 18.2% ─ 35.1%). This was highest in multipara with prior CS at 86.1% (range 6.9% ─ 100%). The proportion of variation in CS that was attributable to the hospital of birth was 11.1% (95% CI, 6.0 ─ 19.4) for elective CS and 2.9% (95% CI, 1.4 ─ 5.6) for emergency CS, after adjustment. Stratifying across parity group, variation between hospitals was greatest for multipara with prior CS. Both types of CS were predicted by increasing age, prior history of miscarriage or stillbirth, prior CS, antenatal complications and private model of care. Conclusion The proportion of variation attributable to the hospital was higher for elective CS than emergency CS suggesting that variation is more likely influenced by antenatal decision making than intrapartum decision making. Multipara with prior CS were particularly subject to variability, highlighting a need for consensus on appropriate care in this group.

Costs of formal and informal care in the last year of life for patients in receipt of specialist palliative care

Background: Economic evaluation of palliative care has been slow to develop and the evidence base remains small. Aim: This article estimates formal and informal care costs in the last year of life for a sample of patients who received specialist palliative care in three different areas in Ireland. Design: Formal care costs are calculated for community, specialist palliative care, acute hospital and other services. Where possible, a bottom-up approach is used, multiplying service utilisation by unit cost. Informal care is valued at the replacement cost of care. Setting/participants: Data on utilisation were collected during 215 ‘after death’ telephone interviews with a person centrally involved in the care in the last year of life of decedents who received specialist palliative care in three areas in Ireland with varying levels of specialist palliative care. Results: Mean total formal and informal costs in the last year of life do not vary significantly across the three areas. The components of formal costs, however, do vary across areas, particularly for hospital and specialist palliative care in the last 3u2009months of life. Conclusion: Costs in the last year of life for patients in receipt of specialist palliative care are considerable. Where inpatient hospice care is available, there are potential savings in hospital costs to offset specialist palliative care inpatient costs. Informal care accounts for a high proportion of costs during the last year of life in each area, underlining the important role of informal caregivers in palliative care.

Differences in Nulliparous Caesarean Section Rates across Models of Care: A Decomposition Analysis

BackgroundTo evaluate the extent of the difference in elective (ELCS) and emergency (EMCS) caesarean section (CS) rates between nulliparous women in public maternity hospitals in Ireland by model of care, and to quantify the contribution of maternal, clinical, and hospital characteristics in explaining the difference in the rates.MethodsCross-sectional analysis using a combination of two routinely collected administrative databases was performed. A non-linear extension of the Oaxaca-Blinder method is used to decompose the difference between public and private ELCS and EMCS rates into the proportion explained by the differences in observable maternal, clinical, and hospital characteristics and the proportion that remains unexplained.ResultsOf the 29,870 babies delivered to nulliparous women, 7,792 were delivered via CS (26.1xa0%), 79.6xa0% of which were coded as EMCS. Higher prevalence of ELCS was associated with breech presentation, other malpresentation, and the mother being over 40xa0years old. Higher prevalence of EMCS was associated with placenta praevia or placental abruption, diabetes (pre-existing and gestational), and being over 40xa0years old. The private model of care is associated with ELCS and EMCS rates 6 percentage points higher compared than the public model of care but this differential is insignificant in the fully adjusted models for EMCS. Just over half (53xa0%) of the 6 percentage point difference in ELCS rates between the two models of care can be accounted for by maternal, clinical and hospital characteristics. Almost 80xa0% of the difference for EMCS can be accounted for.ConclusionsThe majority of the difference in EMCS rates across models of care can be explained by differing characteristics between the two groups of women. The main contributor to the difference was advancing maternal age. The unexplained component of the difference for ELCS is larger; an excess private effect remains after accounting for maternal, clinical, and hospital characteristics. This requires further investigation and may be mitigated in future with the introduction of clinical guidelines related to CS.

Usage of generics in Ireland: Recent trends and policy developments

In 2011, the Irish State spent €1.9bn on pharmaceuticals, amounting to approximately 13% of total public health expenditure. Over the period 2000–2010, Ireland experienced one of the fastest growth rates in per capita pharmaceutical expenditure in the OECD. Concern over pharmaceutical expenditure in Ireland has led to a number of policy changes, targeting primarily the price of pharmaceuticals. More recently, there has been much concern over the low rates of generic usage in Ireland. In 2009, 34% of multiple-source off-patent pharmaceuticals dispensed under the main State pharmaceutical reimbursement schemes in Ireland were generics, in comparison with 71% in the UK. Up to now, the potential for significant savings through the increased use of generics in Ireland has been limited as the price of off-patent pharmaceuticals (including generic pharmaceuticals) was set at a small discount to the patent-holder price. Legislation to introduce a system of reference pricing and generic substitution for 20 leading off-patent pharmaceuticals has recently been enacted. However, reference prices have yet to be set, and so the full scale of any potential savings under the Health (Pricing and Supply of Medical Goods) Act 2013 has yet to be determined. In advance of the new legislation, there has been evidence of a substantial increase in the use of generics in Ireland, although the precise reasons driving this increase are unclear.

How many beds? Capacity implications of hospital care demand projections in the Irish hospital system, 2015-2030

Existing Irish hospital bed capacity is low by international standards while Ireland also reports the highest inpatient bed occupancy rate across OECD countries. Moreover, strong projected population growth and ageing is expected to increase demand for hospital care substantially by 2030. Reform proposals have suggested that increased investment and access to nonacute care may mitigate some increased demand for hospital care over the next number of years, and it is in this context that the Irish government has committed to increase the supply of public hospital beds by 2600 by 2027. Incorporating assumptions on the rebalancing of care to nonhospital settings, this paper analyses the capacity implications of projected demand for hospital care in Ireland to 2030. This analysis employs the HIPPOCRATES macrosimulation projection model of health care demand and expenditure developed in the ESRI to project public and private hospital bed capacity requirements in Ireland to 2030. We examine 6 alternative projection scenarios that vary assumptions related to population growth and ageing, healthy ageing, unmet demand, hospital occupancy, hospital length of stay, and avoidable hospitalisations. We project an increased need for between 4000 and 6300 beds across public and private hospitals (an increase of between 26.1% and 41.1%), of which 3200 to 5600 will be required in public hospitals. These findings suggest that government plans to increase public hospital capacity over the 10xa0years to 2027 by 2600 may not be sufficient to meet demand requirements to 2030, even when models of care changes are accounted for.