Jane Bourke

At what price? a cost-effectiveness analysis comparing trial of labour after previous caesarean versus elective repeat caesarean delivery

Background Elective repeat caesarean delivery (ERCD) rates have been increasing worldwide, thus prompting obstetric discourse on the risks and benefits for the mother and infant. Yet, these increasing rates also have major economic implications for the health care system. Given the dearth of information on the cost-effectiveness related to mode of delivery, the aim of this paper was to perform an economic evaluation on the costs and short-term maternal health consequences associated with a trial of labour after one previous caesarean delivery compared with ERCD for low risk women in Ireland. Methods Using a decision analytic model, a cost-effectiveness analysis (CEA) was performed where the measure of health gain was quality-adjusted life years (QALYs) over a six-week time horizon. A review of international literature was conducted to derive representative estimates of adverse maternal health outcomes following a trial of labour after caesarean (TOLAC) and ERCD. Delivery/procedure costs derived from primary data collection and combined both “bottom-up” and “top-down” costing estimations. Results Maternal morbidities emerged in twice as many cases in the TOLAC group than the ERCD group. However, a TOLAC was found to be the most-effective method of delivery because it was substantially less expensive than ERCD (€1,835.06 versus €4,039.87 per women, respectively), and QALYs were modestly higher (0.84 versus 0.70). Our findings were supported by probabilistic sensitivity analysis. Conclusions Clinicians need to be well informed of the benefits and risks of TOLAC among low risk women. Ideally, clinician-patient discourse would address differences in length of hospital stay and postpartum recovery time. While it is premature advocate a policy of TOLAC across maternity units, the results of the study prompt further analysis and repeat iterations, encouraging future studies to synthesis previous research and new and relevant evidence under a single comprehensive decision model.

In with the new: the determinants of prescribing innovation by general practitioners in Ireland

An important element of the process by which new drugs achieve widespread use is their adoption by GPs. In this paper, we explore the factors that shape the timing of the first prescription of six new drugs by General Practitioners in Ireland. Our analysis is based on a dataset that matches prescription data with data on GP characteristics. We then use duration analysis to explore both equilibrium and non-equilibrium determinants of prescribing innovation. Our study highlights a range of commonalities across all of the drugs considered and suggests the importance of GP and practice characteristics in shaping prescribing decisions. We also find strongly significant, and consistently signed, stock and order effects across these drugs: GPs who have a track record of early adoption tend also to be early adopters of other new drugs; and, the larger the proportion of GPs which have already adopted a new drug the slower is subsequent adoption. Epidemic and learning effects are also evident with slower adoption by rural practices and among those GPs with narrower prescribing portfolios.

THE ROLE OF HRM AND ICT COMPLEMENTARITIES IN FIRM INNOVATION: EVIDENCE FROM TRANSITION ECONOMIES

Innovation is of critical importance for business productivity and economic growth. Firm characteristics and economic geography have been identified as influential drivers of innovation output. More recently, scholars have investigated the influence of Human Resource Management (HRM) practices and Information and Communication Technologies (ICTs) on firm performance. There is evidence that productivity gains from adapting HRM practices are higher if supported by investments in ICT. Therefore, we hypothesise that ICT-use and HRM practices are complementary inputs with respect to firm innovation. Our data source is the Management, Organisation, and Innovation (MOI) Survey which assesses management practices in manufacturing establishments in transition economies. We find that firms that employ HRM practices are more likely to innovate relative to firms that do not use HRM practices. Our analysis also reveals a complementary relationship between ICT-use and HRM practices which positively influences firm innovation performance.

THE INFLUENCE OF HUMAN RESOURCE MANAGEMENT SYSTEMS ON INNOVATION: EVIDENCE FROM IRISH MANUFACTURING AND SERVICE FIRMS

The ability of firms to maximise their innovative potential is fundamental to economic growth. The successful implementation of human resource management (HRM) practices is important for firm performance, and there is a growing understanding of the benefits to firms when HRM practices are applied together. We investigate if HRM practices are significantly more effective when implemented as ‘bundles’ or ‘systems’ of complementarities than when they are implemented individually in Irish manufacturing and service firms. The National Workplace Survey (2009a), a dataset rich with information on HRM practices at the firm level, is employed. HRM bundles relating to performance management and appraisal, knowledge sharing and involvement and empowerment in decision-making are all positively associated with innovation in manufacturing and service firms, and bundles of flexible employment contracts practices positively influence innovation in service firms. In summary, HRM practices when applied together, rather than in isolation, are important for firm innovation.

The influence of experiential learning on medical equipment adoption in general practices

The benefits of the availability and use of medical equipment for medical outcomes are understood by physicians and policymakers alike. However, there is limited understanding of the decision-making processes involved in adopting and using new technologies in health care organisations. Our study focuses on the adoption of medical equipment in Irish general practices which are marked by considerable autonomy in terms of commercial practice and the range of medical services they provide. We examine the adoption of six items of medical equipment taking into account commercial, informational and experiential stimuli. Our analysis is based on primary survey data collected from a sample of 601 general practices in Ireland on practice characteristics and medical equipment use. We use a multivariate Probit to identify commonalities in the determinants of the adoption. Many factors, such as GP and practice characteristics, influence medical equipment adoption. In addition, we find significant and consistent evidence of the influence of learning-by-using effects on the adoption of medical equipment in a general practice setting. Knowledge generated by experiential or applied learning can have commercial, organisational and health care provision benefits in small health care organisations.

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, womens 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 womens 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. Womens 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.

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 womens 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.

Income-related inequalities and inequities in Irish healthcare utilization

The aim of this article is to determine the extent of and changes in horizontal inequity in general practitioner and medical specialist utilization in Ireland from 1997 to 2001. Horizontal equity refers to people in equal need of treatment receiving similar treatment regardless of income. After accounting for the differences in the need for such care, this study reports relatively low pro-poor horizontal inequity with respect to general practitioner utilization, increasing slightly between 1997 and 2001. This study finds that a generally pro-rich horizontal inequity distribution in 1997 is replaced by a generally pro-poor distribution in 2001 with respect to medical specialist utilization.

THE INFLUENCE OF THE MANAGER ON FIRM INNOVATION IN EMERGING ECONOMIES

The focus of this paper is on the relatively under-researched area of the influence of management on innovation activities for firms in emerging economies. Many emerging economies adopt a strategy of outward-oriented development with the aim to enhance innovation performance through Foreign Direct Investment (FDI) and international trade. However, attention should be paid to firm mechanisms, including intangibles, that may enable a firm to benefit from the more tangible performance-enhancing effects. It is through such a lens that we examine firm innovation in emerging economies, focusing on how variations in management experience, management practices and management incentives impact innovation performance. We employ a production function approach to identify the effect of the management environment on innovation diversity for firms in emerging economies. Our diversity of innovation measure takes account of five types of innovation activity, and is indicative of the degree of ‘innovativeness’ that the firm possesses. A Tobit estimation technique is employed. Innovation decisions typically involve managers as filtering mechanisms to consider a range of external and internal factors that enhance the likelihood of innovation outcomes. Our results indicate that management experience, management practices and management incentives are all important in determining innovation activities in firms from emerging economies. Our analysis reveals the importance of the management environment in explaining innovation differences at the level of the firm in emerging economies. Therefore, strategies to empower and support managers in emerging economies should be considered alongside outward-orientated development strategies.

Value for money? An examination of the relationship between need and cost in intellectual disability services

The recent economic crisis along with changing demographic trends has stimulated an increased interest in the value obtained from social care expenditure so as to ensure the sustainability of systems in the future. In Ireland, the Department of Health, further to a recent review of its disability services, commited to a new approach that will reshape and redesign its service provision. It specifically outlined a reorganisation of financing services, from a model of prospective block grant funding to a system of individualised budgeting based on an assessment of need. This paper examines the relationship between need, service utilisation and cost for high-cost users of adult intellectual disability residential services in an Irish county under the current model of block grant financing. The analysis reported is based on primary data collected from 68 high-cost users of adult intellectual disability residential services in an Irish county in 2013. Statistical analysis was performed to identify the relationship between need and cost, and also to examine the variations in the cost of support between the service provider organisations. Our analysis determined an association between need and cost, with poorer levels of psychological well-being related to higher costs. However, the study found no evident relationship between staff/client ratios, the numbers of staff engaged at the residential units and need. An examination of cost variations between the service provider organisations revealed that agency status; service unit size; client and staff characteristics all contributed to variations in the cost of care. This study supports the development of a national resource allocation framework as being fundamental to the equitable and transparent distribution of scarce resources, as recommended by the Department of Health in Ireland.