Brendan McElroy

Malaria prevention in The Gambia: patterns of expenditure and determinants of demand at the household level

Objective  To provide a better understanding of (1) the amounts households in The Gambia spend on a wide variety of malaria prevention measures, (2) how expenditure fluctuates throughout the year and (3) the main determinants of expenditure.

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

ObjectiveThis study aims to provide a better understanding of the amounts spent on different malaria prevention products and the determinants of these expenditures.Methods1,601 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.Findings68% 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

Day Care Compared With Inpatient Management of Nausea and Vomiting of Pregnancy: A Randomized Controlled Trial

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

Obesogenic island: the financial burden of private transport on low-income households

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.ConclusionExpenditure 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.

The hidden cost of clinical audit: a questionnaire study of NHS staff

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

Patient level costing in Ireland: process, challenges and opportunities

BACKGROUND The physical and social environment influences access to a healthy lifestyle, of which transport is one determining factor. This paper estimates the cost of transport on the island of Ireland. METHODS Budget standards were developed on the basis of costs of baskets of core goods and services required for daily living. The transport budget was based on the needs of an urban living family. Financial capacity of the family relative to transport basket costs was determined. RESULTS Transport costs vary depending on family type and car ownership. The motoring costs for a family with two unemployed adults, with a weekly financial capacity of 388.28 euros and 427.70 euros, respectively, for the Republic of Ireland and Northern Ireland, amount to 94.78 euros and 74.68 euros, representing 18 and 10% of the familys weekly income. CONCLUSION The prohibitive costs of private transport present an opportunity for policy makers to consider creating supportive environments incorporating the more cost-effective and environmentally friendly options of public transport. Without such measures, dependence on private transport will exacerbate the incidence of food poverty and the health inequalities consequent upon it.

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

OBJECTIVES To determine the full cost of clinical audit in one health board area and extrapolate the result of Scotland. METHODS A questionnaire was sent ot a representative sample of NHS staff to determine time spent on clinical audit. This was combined with cost data from clinical audit budgets and unit cost data for staff time. RESULTS Seventy-two percent of staff participated in clinical audit at some point in time. Medical staff were significantly more likely to participate in audit than non medical staff (P <0.0001). Those who participated in clinical audit devoted only a small proportion of time to it. However, due to the high participation rates in clinical audit, this aggregated to a significant amount. In Forth Valley the total cost was estimated to be pound 1.72m (pound 1.37m-pound 2.10m) and in Scotland pound 36.3m (pound 29.6m-pound 44.0m). Staff time accounted for over 80% of the total cost of clinical audit. CONCLUSIONS Clinical audit is widespread within the Scotish NHS and the total cost of staff time devoted to audit is substantial. Research is needed into the value of clinical audit and the potential cost implications of clinical governance need to be explicitly recognised.

An economic analysis of money follows the patient

BackgroundIn 2013, the Department of Health released their policy paper on hospital financing entitled Money Follows the Patient. A fundamental building block for the proposed financing model is patient level costing.AimThis paper outlines the patient level costing process, identifies the opportunities and considers the challenges associated with the process in the Irish hospital setting.MethodsMethods involved a review of the existing literature which was complemented with an interview with health service staff.ResultsThere are considerable challenges associated with implementing patient level costing including deficits in information and communication technologies and financial expertise as well as timeliness of coding. In addition, greater clinical input into the costing process is needed compared to traditional costing processes. However, there are long-term benefits associated with patient level costing; these include empowerment of clinical staff, improved transparency and price setting and greater fairness, especially in the treatment of outliers. These can help to achieve the Government’s Health Strategy.ConclusionsThe benefits of patient level costing need to be promoted and a commitment to investment in overcoming the challenges is required.

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

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 patients 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.

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

IntroductionAs part of the proposed changes to re-design the Irish health-care system, the Department of Health (money follows the patient—policy paper on hospital financing, 2013b) outlined a new funding model for Irish hospitals—money follows the patient (MFTP). This will replace the existing system which is predominately prospective with hospitals receiving a block grant per annum. MFTP will fund episodes of care rather than hospitals. Thus, hospital revenue will be directly linked to activity [activity-based funding (ABF)].Theory and literature reviewWith ABF there is a fundamental shift to a system where hospitals generate their own income and this changes incentive structures. While some of these incentives are intended (reducing cost per case and increasing coding quality), others are less intended and less desirable. As a result, there may be reductions in quality, upcoding, cream skimming and increased pressure on other parts of the health system. In addition, MFTP may distort health system priorities. There are some feasibility concerns associated with the implementation of MFTP. Data collection, coding and classification capacity are crucial for its success. While MFTP can build on existing systems, significant investment is required for its success. This includes investment in coding and classification, infrastructure, skills, IT, contracting, commissioning, auditing and performance monitoring systems.ConclusionsDespite the challenges facing implementers, MFTP could greatly improve the transparency and accountability of the system. Thus if the downside risks are managed, there is potential for MFTP to confer significant benefits to Irish hospital care.