Charles Normand

Clinical outcomes, quality of life, and costs in the North Thames Dialysis Study of elderly people on dialysis: a prospective cohort study

BACKGROUND Evidence-based health policy is urgently needed to meet the increasing demand for health services among elderly people, particularly for expensive technologies such as renal-replacement therapy. Age has been used to ration dialysis, although not always explicitly, despite the lack of rigorous empirical evidence about how elderly people fare on dialysis. We undertook a comprehensive assessment of outcomes in patients 70 years or over. METHODS We did a 12-month prospective cohort study of outcomes in 221 patients with end-stage renal failure aged 70 years or over recruited from four hospital-based renal units. We assessed 1-year survival in 125 incident patients (70-86 years) and disease burden (hospital admissions, quality of life, costs) in 174 prevalent patients (70-93 years). FINDINGS 1-year survival rates were: 71% overall; 80%, 69%, and 54% in patients 70-74 years, 75-79 years, and 80 years and older, respectively (p=0.008); and 88%, 71%, and 64% in patients with no, one, or two or more comorbid conditions, respectively (p=0.056). Cox regression analyses showed that mortality was significantly associated with age 80 years and older (relative risk 2.79 [95% CI 1.28-6.93]) and peripheral vascular disease (2.83 [1.29-6.17]), but not with diabetes, ischaemic heart disease, cerebrovascular disease, chronic obstructive airways disease, sex, or treatment method. In terms of disease burden, hospital admissions represent a low proportion of costs and was not required by a third of patients, mental quality of life in elderly dialysis patients was similar to that of elderly people in the general population, and the average annual cost per patient of 20802 (US

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

31200) (68% dialysis treatment, 1% transport, 19% inpatient hospital admissions, 12% medications) was within the range of other life-extending interventions. INTERPRETATION Our results suggest that age alone should not be used as a barrier to referral and treatment and emphasise the need to consider the benefits of dialysis in elderly people. Indicators of the ability to benefit from treatment, rather than chronological age, should be used to develop policies that ensure equal access to care for all.

Comparison of hypertonic saline and alternate-day or daily recombinant human deoxyribonuclease in children with cystic fibrosis: a randomised trial

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.

Chronic pain in the Republic of Ireland—Community prevalence, psychosocial profile and predictors of pain-related disability: Results from the Prevalence, Impact and Cost of Chronic Pain (PRIME) study, Part 1

BACKGROUND Daily recombinant human deoxyribonuclease (rhDNase) is an established but expensive treatment in cystic fibrosis. Alternate-day treatment, if equally effective, would reduce the drug cost. Hypertonic saline improved lung function to the same degree as rhDNase in short-term studies. We compared the effectiveness of daily rhDNase, hypertonic saline, and alternate-day rhDNase in children with cystic fibrosis. METHODS In an open cross-over trial, 48 children were allocated in random order to 12 weeks of once-daily rhDNase (2.5 mg), alternate-day rhDNase (2.5 mg), and twice-daily 5 mL 7% hypertonic saline. The primary outcome was forced expiratory volume in 1 s (FEV(1)). Secondary outcomes were forced vital capacity, number of pulmonary exacerbations, weight gain, quality of life, exercise tolerance, and the total costs of hospital and community care. FINDINGS Mean FEV(1) increased by 16% (SD 25%), 14% (22%), and 3% (21%) with daily rhDNase, alternate-day rhDNase, and hypertonic saline, respectively. There was no difference between daily and alternate-day rhDNase (2% [95% CI -4 to 9], p=0.55). However, daily rhDNase showed a significantly greater increase in FEV(1) than hypertonic saline (8% [2 to 14], p=0.01). The average difference in 12-week cost between daily and alternate-day rhDNase was pound513 (95% CI -546 to 1510) and that between daily rhDNase and hypertonic saline was pound1409 (440 to 2318). None of the secondary clinical outcomes showed significant differences between treatments. INTERPRETATION Hypertonic saline, delivered by jet nebuliser, is not as effective as daily rhDNase, although there is variation in individual response. There is no evidence of a difference between daily and alternate-day rhDNase.

Primary care trusts

&NA; The aims of the PRIME study (Prevalence, Impact and Cost of Chronic Pain) were 3‐fold: (1) to determine the point prevalence of chronic pain in Ireland; (2) to compare the psychological and physical health profiles of those with and without chronic pain; and (3) to explore a predictive model of pain‐related disability. A postal survey of 3136 people was conducted with a representative community‐based sample of adults. Measures were obtained for sociodemographic variables, physical and psychological well‐being, depressive symptoms, presence of pain, pain severity, pain‐related disability, and illness perceptions. Responses were received from 1204 people. The prevalence of chronic pain was 35.5% (95% CI = 32.8–38.2) (n = 428). No gender difference in prevalence was found. Prevalence of pain increased with age and was associated with manual employment. The most commonly reported site of pain was the lower back (47.6%); however, multiple pain sites was the norm, with more than 80% of participants reporting more than 1 pain site. Approximately 12% of participants were unable to work or were on reduced work hours because of pain. Of those with chronic pain, 15% met the criteria for clinically relevant depression compared with 2.8% of those without pain. A multiple regression analysis, predicting 67% of variance, showed that pain intensity was the strongest predictor of pain‐related disability. Depression and illness perceptions were also predictive of pain‐related disability, after controlling for the effects of pain intensity. Chronic pain is a prevalent health problem in Ireland and is associated with significant psychological and functional disability. Psychological factors appear to influence the level of pain‐related disability. Chronic pain affects approximately one‐third of the population in Ireland, and depressive symptoms occur 5 times more often than in persons without chronic pain.

Dual job holding practitioners in Bangladesh: an exploration

Premature reorganisation, with mergers, may be harmful

What can be concluded from the Oxcheck and British family heart studies: commentary on cost effectiveness analyses

This paper analyses the system of financial and non-financial incentives underlying job preferences of doctors in Bangladesh who work both in government health services and in private practice. The study is based on a survey of 100 government-employed doctors with private practice, across different levels of care and geographical areas. In-depth interviews were carried out in a sub-sample of 28 respondents. The study explores the beliefs and attitudes towards the arrangements of joint private/public practice, establishes profiles of fee levels and earnings and examines the options to change the incentive system in a way that ensures an increased involvement of dual job holding practitioners in the priority areas of care. Consultation fees were Tk120 on average (range Tk20-300) and found to be correlated with the qualification of the practice owner and the type of service offered. A majority of the respondents reported at least to double their government income by engaging in private practice. Significant predictors of total income included the number of patients seen in private practice (p=0.000), employment in a secondary or tertiary care facility (p=0.001) and ownership of premises for private practice (p=0.033). Age was found to be marginally significant (p=0.084). No association was found between total income and specialisation, private practice costs, level of government salary or a degree from abroad. The data suggest that doctors have adopted individual strategies to accommodate the advantages of both government employment and private practice in their career development, thus maximising benefit from the incentives provided to them e.g. status of a government job, and minimising opportunity costs of economic losses e.g. lower salaries. Commitment to government services was found to be greater among doctors in primary health care who reported they would give up private practice if paid a higher salary. Among doctors in secondary and tertiary care, the propensity to give up private practice was found to be low. Financial incentives that aim to increase numbers of doctors in rural areas, such as a non-private-practice allowance, are more likely to be appreciated by doctors who are at the beginning of their career. Improved training and career opportunities also appear to be of high importance for job satisfaction. Policy changes to ensure a better resource allocation to the priority areas of the health sector have to reflect an understanding of the incentives generated by the organisational and financial context within which dual job holding practitioners operate.

Measuring and managing the work environment of the mid-level provider – the neglected human resource

Abstract Objectives: To provide a commentary on the economic evaluations of the Oxcheck and British family heart studies: direct comparison of their relative effectiveness and cost effectiveness; comparisons with other interventions; and consideration of problems encountered. Design: Modelling from cost and effectiveness data to estimates of cost per life year gained. Subjects: Middle aged men and women. Interventions: Screening for cardiovascular risk factors followed by appropriate lifestyle advice and drug intervention in general practice, and other primary coronary risk management strategies. Main outcome measures: Life years gained; cost per life year gained. Results: Depending on the assumed duration of risk reduction, the programme cost per discounted life year gained ranged from £34 800 for a 1 year duration to £1500 for 20 years for the British family heart study and from £29 300 to £900 for Oxcheck. These figures exclude broader net clinical and cost effects and longer term clinical and cost effects other than coronary mortality. Conclusions: Despite differences in underlying methods, the estimates in the two economic analyses of the studies can be directly compared. Neither study was large enough to provide precise estimates of the overall net cost. Modelling to cost per life year gained provides more readily interpretable measures. These estimates emphasise the importance of the relatively weak evidence on duration of effect. Only if the effect lasts at least five years is the Oxcheck programme likely to be cost effective. The effect must last for about 10 years to justify the extra cost associated with the British family heart study. Key messages A more meaningful measure, cost per life year gained, requires modelling of the longer term effect of that risk reduction In terms of life years gained, the more intensive British family heart study intervention was more effective but less cost effective than the Oxcheck intervention The cost effectiveness of these relative to other interventions crucially depends on the assumed duration of the risk reduction, which must persist for at least five years for either programme to be viewed as cost effective Larger trials with longer follow up would be required to fully assess the long term effectiveness and overall cost effectiveness of population cardiovascular screening

Prospective Cohort Study of Hospital Palliative Care Teams for Inpatients With Advanced Cancer: Earlier Consultation Is Associated With Larger Cost-Saving Effect

BackgroundMuch has been written in the past decade about the health workforce crisis that is crippling health service delivery in many middle-income and low-income countries. Countries having lost most of their highly qualified health care professionals to migration increasingly rely on mid-level providers as the mainstay for health services delivery. Mid-level providers are health workers who perform tasks conventionally associated with more highly trained and internationally mobile workers. Their training usually has lower entry requirements and is for shorter periods (usually two to four years). Our study aimed to explore a neglected but crucial aspect of human resources for health in Africa: the provision of a work environment that will promote motivation and performance of mid-level providers. This paper explores the work environment of mid-level providers in Malawi, and contributes to the validation of an instrument to measure the work environment of mid-level providers in low-income countries.MethodsThree districts were purposively sampled from each of the three geographical regions in Malawi. A total of 34 health facilities from the three districts were included in the study. All staff in each of the facilities were included in the sampling frame. A total of 153 staff members consented to be interviewed. Participants completed measures of perceptions of work environment, burnout and job satisfaction.FindingsThe Healthcare Provider Work Index, derived through Principal Components Analysis and Rasch Analysis of our modification of an existing questionnaire, constituted four subscales, measuring: (1) levels of staffing and resources; (2) management support; (3) workplace relationships; and (4) control over practice. Multivariate analysis indicated that scores on the Work Index significantly predicted key variables concerning motivation and attrition such as emotional exhaustion, job satisfaction, satisfaction with the profession and plans to leave the current post within 12 months. Additionally, the findings show that mid-level medical staff (i.e. clinical officers and medical assistants) are significantly less satisfied than mid-level nurses (i.e. enrolled nurses) with their work environments, particularly their workplace relationships. They also experience significantly greater levels of dissatisfaction with their jobs and with their profession.ConclusionThe Healthcare Provider Work Index identifies factors salient to improving job satisfaction and work performance among mid-level cadres in resource-poor settings. The extent to which these results can be generalized beyond the current sample must be established. The poor motivational environment in which clinical officers and medical assistants work in comparison to that of nurses is of concern, as these staff members are increasingly being asked to take on leadership roles and greater levels of clinical responsibility. More research on mid-level providers is needed, as they are the mainstay of health service delivery in many low-income countries. This paper contributes to a methodology for exploring the work environment of mid-level providers in low-income countries and identifies several areas needing further research.

Effectiveness of Palliative Day Care in Improving Pain, Symptom Control, and Quality of Life

PURPOSE Previous studies report that early palliative care is associated with clinical benefits, but there is limited evidence on economic impact. This article addresses the research question: Does timing of palliative care have an impact on its effect on cost? PATIENTS AND METHODS Using a prospective, observational design, clinical and cost data were collected for adult patients with an advanced cancer diagnosis admitted to five US hospitals from 2007 to 2011. The sample for economic evaluation was 969 patients; 256 were seen by a palliative care consultation team, and 713 received usual care only. Subsamples were created according to time to consult after admission. Propensity score weights were calculated, matching the treatment and comparison arms specific to each subsample on observed confounders. Generalized linear models with a γ distribution and a log link were applied to estimate the mean treatment effect on cost within subsamples. RESULTS Earlier consultation is associated with a larger effect on total direct cost. Intervention within 6 days is estimated to reduce costs by -