Preliminary Assessment of Appropriateness of Emergency Care Service Use: Actions Taken and Consultations Obtained Before Emergency Care Presentation

Inappropriate use of emergency care services can increase hospital readmissions and related costs. This pilot, cross-sectional survey project determined whether home health care patients who receive emergency care services during a Medicare-approved home care episode sought consultation from health care professionals before they made the emergency care visit. The two research questions were: (a) What actions were taken by the patient before making an emergency care visit?; (b) If prior consultation was obtained, what were the suggestions? Preliminary data were obtained from a Michigan-based, Medicare-certified, not-for-profit home health agency affiliated with a university health system. A two-page questionnaire recorded up to three emergency care visits. Volunteer participants were Medicare patients who had no cognitive deficits and were able to communicate with home health care providers (HHCPs) by themselves. Thirty-five emergency care visits were reported; 31 (88.6%) Medicare patients participated and 4 (11.4%) of them had two emergency care visits. Before the patients made an emergency care visit, they most often called their primary care physicians (PCPs; N = 20, 57.1%), followed by the HHCPs (N = 10, 28.6%). All 20 patients who contacted their PCPs and 7 patients who contacted their HHCPs were advised to seek emergency care services. In 20 emergency care visits the patient was admitted for an acute hospital stay; the other 15 patients went home. Most patients contacted their PCPs or HHCPs before they went to an emergency department or urgent care facility. These results implied that PCPs and HHCPs seemed to perceive that the need for emergency care should be determined at an emergency room or urgent care facility. This study was unable to differentiate the need for emergency care services or the appropriateness of the advice given by PCPs or HHCPs when the home care patients were under the care of a medical team.     

Health care and lost productivity costs of overweight and obesity in New Zealand

Objective: To estimate the costs of health care and lost productivity attributable to overweight and obesity in New Zealand (NZ) in 2006. Methods: A prevalence‐based approach to costing was used in which costs were calculated for all cases of disease in the year 2006. Population attributable fractions (PAFs) were calculated based on the relative risks obtained from large cohort studies and the prevalence of overweight and obesity. For each disease, the PAF was multiplied by the total health care cost. The costs of lost productivity associated with premature mortality were estimated using both the Human Capital approach (HCA) and Friction Cost approach (FCA). Results: Health care costs attributable to overweight and obesity were estimated to be NZ$624m or 4.4% of New Zealand's total health care expenditure in 2006. The costs of lost productivity using the FCA were estimated to be NZ$98m and NZ$225m using the HCA. The combined costs of health care and lost productivity using the FCA were $722m and $849m using the HCA. Conclusion: The cost burden of overweight and obesity in NZ is considerable. Implications: Policies and interventions are urgently needed to reduce the prevalence of obesity thereby decreasing these substantial costs.     

Palliative care in public health: a formal and content-related analysis of European journals

Public health and health care science take on an important role in the further development of palliative care. This study examines to what degree palliative care is represented in the pertinent academic journals of public health and health care science and what the major subjects are. We analysed the European journals that were listed in the Journal Citation Reports in the categories health care science and services, public, environmental and occupational health, as well as health policy and services. The literature search was conducted in the journals identified for the years 1996 through 2005, using the terms palliative care*, palliative medicine*, terminal care* and hospice care*. The analyses were based on the quantity of publications in the journals, the publication years, the impact factors and the subjects focused on. There were 82 journals included. Altogether, 57,737 publications appeared during the analysis period; 166 papers were on palliative care (0.3% of all papers). The majority of palliative care articles (55%, n = 91) were concentrated in a very small circle of journals (4%, n = 3). The absolute quantity of palliative publications and their percentage among all publications have continuously increased from 0.1% in 1996/1997 to 0.4% in 2004/2005. The largest group of papers on the subject (42%, n = 70) appeared in journals with impact factors less than 1, whereas the largest group of all papers was found in journals with impact factors of 1–1.999 (51%, n = 15,732). Most papers focus on patient orientation and health professionals’ perspective and education; subjects such as health care utilization and barriers are less frequently covered. There is need for more research on palliative care relevant for public health and health care science in terms of reach and top-level impact. For example, the research questions should deal with health care utilization and potential social and cultural barriers. The interdisciplinary community of public health sets the stage for the required collaborative research activities.     

The demand for private health care in the UK

Policy change has eroded the entitlement of UK residents to free state-provided health care, with a resulting rise in the use of the private sector. This paper examines the choice between public and private health care. It models the use of private health care as a function of its costs and benefits relative to state care and no care. The results indicate a difference between users of private care and other care, and the importance of past use as a predictor of current use. But they also show considerable movement between the public and private sectors, indicating a complex relationship in public and private sector use.     

GP Clinic: promoting access to primary health care for mental health service clients

Objective: To evaluate an innovative rural service offering comprehensive primary health care for mental health service clients. Design: A formative evaluation using mixed methods. Setting: A rural NSW community. Participants: Fifteen health care providers and 120 adult clients. Intervention: A monthly clinic held in a general practice to provide primary health care for clients of the community mental health team. Main outcome measures: Client utilisation and clinic activity data. Provider views of service effectiveness, possible improvements and sustainability. Results: The GP Clinic has operated successfully for 2.5 years without access block. Some 52% of clients had no physical illness and 82% were referred to other health and community services. In total, 40% continued to attend the clinic while 32% went on to consult a GP independently. Client access to care improved as did collaboration between the community mental health team and primary care providers. Conclusion: The GP Clinic is a straightforward and flexible service model that could be used more widely.     

Exploring the potential for social prescribing in pre-hospital emergency and urgent care: A qualitative study

There is a sustained increase in demand for emergency and urgent care services in England. The NHS Long Term Plan aims to reduce the burden on emergency hospital services through changing how pre-hospital care operates, including increased delivery of urgent care. Given the recognised potential of social prescribing to address wider determinants of health and reduce costs in other settings, this study aimed to understand the role that social prescribing can play in pre-hospital emergency and urgent care from the perspectives of staff. Semi-structured interviews (n = 15) and a focus group (n = 3) were conducted with clinical staff (n = 14) and non-clinical health advisors (n = 4) from an English Ambulance Service covering emergency (999) and non-emergency (111) calls. Data were analysed using a pre-defined framework: awareness of social prescribing; potential cohorts suitable for social prescribing; and determinants of social prescribing. Awareness and knowledge of social prescribing was limited, though when social prescribing was explained to participants they almost universally recognised its benefits for their role. Social prescribing was considered to be most beneficial to those calling for reasons relating to mental health, loneliness or social isolation, in particular older people and frequent users of 999 and 111 services. Determinants of social prescribing were identified across the micro (patient and staff acceptability of social prescribing), meso (triage and referral pathways) and macro (commissioning and funding) levels of analysis. This is the first empirical study to explore social prescribing in pre-hospital emergency and urgent care services, which suggests that it has potential to improve quality of care at the point of people accessing these services. There is a pressing need to address the micro, macro and meso level determinants identified within this study, in order to support staff within pre-hospital emergency and urgent care services to socially prescribe.     

Evaluation of a community based dental clinic for youth experiencing homelessness in Brisbane

The relationship between homelessness and ill health is complex, and many risk factors for homelessness such as unemployment, low income, and substance abuse are also risk factors for poor oral health. In order to overcome barriers to access dental care, previous studies have recommended integrating dental care, referral pathways, and information within the overall care provided by support services available to people at risk of homelessness. This study aimed to evaluate a dental service developed and implemented to improve access to oral health care of disadvantaged youth in Brisbane. A mobile dental clinic run by volunteer dental professionals was implemented into a community organisation for disadvantaged youth. Participants were clients of Brisbane Youth Services who were disadvantaged youth, ≤25 years and attended the dental clinic in a 1 year period. A questionnaire collected demographic information, a self‐assessment of oral health and an evaluation of their experiences with the dental clinic. Clinical data including DMFT, appointment attendance and items of service provided were collected. One hundred and twelve clients participated in the four dental clinic weeks and its evaluation. Cost was the greatest reported barrier to accessing dental care among participants. More than half (57%) of participants who pre‐booked an appointment failed to attend. A total of 640 services were delivered, with an estimated value of $48,000. The majority (69%, n = 444) of the services provided were preventative services. Almost all of the clients felt the service they received was suitable for them (97%, n = 98) and would use the service again (98%, n = 99). This dental clinic model is feasible and sustainable due to its integration into an existing homeless youth service, low running costs, acceptability to clients and an interest by dental practitioners to volunteer. It provides a useful model which could be scaled up and implemented in other regions.     

Integrating Children's Health Services: Evaluation of a National Demonstration Project

Objectives: Increasingly, the public and private sectors are turning to service integration efforts to reduce, if not eliminate, barriers to needed care created by categorical programs. In 1991, the Robert Wood Johnson Foundation established a new national demonstration project, called the Child Health Initiative, intended to test the feasibility of developing mechanisms at the community level to coordinate the delivery of health services and to pay for those services through a flexible pool of previously categorical funds. This article presents the findings of an independent evaluation of the Child Health Initiative. Method: The evaluation utilized a combination of qualitative methods to assess and describe the experiences of the communities as they developed and implemented integrated health services. It used a repeated measures design involving two site visits and interim telephone interviews, as well as review of documents. Results: Overall, the demonstration project achieved mixed success. Both care coordination and the production of community health report cards were found to be achievable within the relatively short life of the foundation grant. However, many sites experienced significant delays in the production of report cards and implementing care coordination plans because the sites largely did not benefit from the successful models already in existence. Little clear progress was made in implementing the decategorization component of the project. Sites experienced difficulties due to lack of previous experience with this new undertaking, the inability to secure active cooperation from local, state, and federal agencies, the relatively short duration of the project, and other factors. Conclusions: A number of lessons were learned from this project that may be useful in future decategorization experiments, including (1) a clear understanding of the concept and its applications among all parties is essential, (2) high-level political commitments to the effort are needed between all levels of government, (3) adequate technical assistance should be provided to surmount technical considerations in establishing a workable approach to decategorization, and (4) decategorization and service integration efforts should focus on both the health and social sectors.     

The cost of quality improvements due to integrated management of childhood illness (IMCI) in Uganda

The goal of this paper is to measure the marginal change in facility-level costs of medical care for children under five due to an increase in service quality achieved through the integrated management of childhood illness (IMCI) strategy. Since the beneficial effects of IMCI training on child health outcomes are due to IMCI's effects on service quality, costs of IMCI are regressed against measures of service quality in this paper. Our model shows that quality, as measured by a WHO-index of integrated child assessment is 44% higher in facilities with at least one health worker trained in IMCI as compared to facilities with no health workers trained in IMCI, adjusting for facility utilization as well as type of facility ownership. Our marginal analysis that tied IMCI training to quality and quality to costs shows that on the margin, investing in IMCI training at a primary facility level can yield a significant 44.3% improvement in service quality for a modest 13.5% increase in annual facility costs.     

Reduced list costings: Examination of an informed short cut in mental health research

The demands for cost information in health services are many and various but the supply of such information is less than might be expected and is compounded by the expense of undertaking costs research. This paper examines a short cut to mental health research which, if certain rules and conventions are obeyed, can still produce valid costs data. By distilling evidence from previous research a reduced list of services is identified which accounts for the greater part of the total costs of care packages. By concentrating on these key services, 94 per cent of the total costs of care were predicted for discharged long-stay patients and no less than 91 per cent for people supported by community psychiatric nurses. The results suggest that this reduced list method can work well where the aim is to obtain broad orders of magnitude for the costs of care. By reducing the resources required for research, the approach could expand the current costs information base and move towards meeting the pressing practice demands for costs data.