Caring for ventilated patients in the community: a pilot study examining costs, quality of life and preferences

This paper describes a pilot study that identifies the implications for resource use when ventilated patients are moved from hospital to the community, and pilots two generic health status survey instruments to measure quality of life experienced in the community for use in a future full evaluation. A group of 11 ventilated patients living in the community were interviewed to identify their resource use, and the SF-36 questionnaire, EuroQol questionnaire and Patient Generated Index were used to investigate implications on quality of life and whether these measures were suitable for use in this group of patients. The main results indicate that the cost of care varies considerably between hospital and community and across patients. The quality of life measures proved inadequate, and highlighted the problems of measuring quality of life for patients with deteriorating health status. All patients much preferred home care to hospital care. A full multi-disciplinary evaluation is required to determine an effective method of providing the care.     

The costs of community care for former long-stay psychiatric hospital residents

Support for people with long-term mental health problems is gradually being relocated from hospital to community settings. One of the questions raised by the shifting locus of care concerns the cost implications. This paper describes the cost of supporting people with long-term mental health problems who have moved to the community after many years in hospital. After summarizing the national and local policy contexts, and the methodology, the paper describes the people who have moved to the community, the services they use, and the cost of community care.     

The impact of research on hospital costs of care: an empirical study

The goal of this study was to examine the impact of research activities on hospital costs and lengths of stay in French public hospitals. Our data consist of a random sample of 30 000 inpatient stays in 38 hospitals that were extracted from the French Hospital Cost Survey database. Hospital characteristics were added using data from a French national survey and performing a bibliometric study. This is a retrospective study of hospitalizations. We used multilevel modelling. We considered separate models to explain the cost per day and the length of hospital stay (LOS). Research output was defined based on the quartiles of the distribution of the number of impact‐weighted scientific publications produced in our sample of hospitals over a 6‐year period. Research production was associated with a higher cost of care. The cost per day was 19% higher in hospitals in the 3rd quartile and 42% higher in hospitals in the 4th quartile compared to that in hospitals that were not involved in research activities. This result was sensitive to the type of care under consideration. The effect was stronger in oncology but not significant in routine care. Scientific production did not impact the LOS. Copyright © 2010 John Wiley & Sons, Ltd.     

Evaluating innovation in general practice: a pragmatic framework using programme budgeting and marginal analysis

BACKGROUND: Innovation in primary care in the UK, in terms of new service developments, is occurring at a fast pace. However, little information is available on the costs and benefits of these changes. OBJECTIVES: We aimed to illustrate the use of programme budgeting and marginal analysis (PBMA) as a framework for evaluating innovation in primary care, using an example of practice-based diabetes care. The aim was to examine changes in the use of practice resources and the changes in benefits to patients, following the introduction of a diabetes clinic. METHODS: PBMA is a form of pragmatic economic evaluation combining practice data for the 'before' period and data from the literature to model the 'after' period. RESULTS: In 1995/6, the total amount of resources devoted to diabetes care in the two practices was 145813 pound sterling (634 pound sterling per patient). Of this sum, 62% was allocated to out-patient visits, 28% to prescribing, 5% to hospital admissions, 2% to GP consultations and 2% to tests. The literature suggests that a nurse-run diabetes clinic would result in similar health outcomes and better access for patients. The introduction of such a clinic could potentially save each practice between 2000 pound sterling and 16000 pound sterling per year. This result takes into account a wide range of assumptions about changes in resource use, but does depend on the findings of previous studies. CONCLUSIONS: The results of this study show that PBMA is a useful framework for helping practices be accountable and make 'evidence- based' decisions about service innovations in primary care.      

Formal support of stroke survivors and their informal carers in the community: a cohort study

This cohort study, aims to explore formal care provision to stroke survivors and their informal carers in the community in the UK. An initial cohort of 105 cohabitant carers of first-time stroke patients was recruited while the stroke patient was in hospital. Structured face-to-face interviews were carried out with carers prior to discharge of the stroke patient home, at 6 weeks after discharge, and 15 months after stroke. Questionnaires included measures of psychological health (CIS-R), physical health (self-rated health), social well-being (relationship quality and Sarason's social support questionnaire), handicap of the stroke survivor (Oxford Handicap Scale) and formal community support (amount of formal support and carer satisfaction). Multiple services were involved with most survivor-carer pairs (mean 5.4; range 2-9; SD = 1.7), and 74% of carers were satisfied with formal support provided. Number of services decreased with time (5.5 versus 4.1, t = 4.201, d.f. = 52, P < 0.001, 95% confidence interval: 0.71-2.01) but not time allocated. Using stepwise linear regression, service provision early after discharge was predicted by: level of handicap, recruitment centre, carer self-rated health, number of informal supporters and other care commitments. Satisfaction was predicted by quality of informal support and activity restriction. Fifteen months after stroke, predictors of formal care were: level of handicap, quality of informal support and previous caring experience. Predictors of satisfaction were: quality of the relationship between the stroke survivor and carer, age and mood. Quality of services was good, but carers lacked information, had insufficient help and were not consulted enough. Carer distress is common, yet not currently a factor influencing support provision. Formal care provided adapts with time reflecting the importance of quality of support from friends and family rather than quantity of informal supporters. These factors should be taken into consideration when planning and providing formal support for stroke survivors and their carers.     

Economic impact of a hepatitis A epidemic in a mid-sized urban community: the case of Spokane,Washington

Data reported here represent an effort to build on previous work regarding the costs of hepatitis A. We expand this work to include an estimation of the costs of hepatitis A on a community wide basis. In addition to calculating the costs of disease management and health care delivery, we include an analysis of additional child care costs, lost productivity, costs associated with outbreak management, and the impact on affected restaurants that required public notification and the administration of Immune Globulin to patrons. The work reported here is specific to Spokane county, Washington. The objective is to enable the Spokane Regional Health District to communicate to the community costs of managing an outbreak of hepatitis A and to inform implementation of a hepatitis A vaccination program on a community wide basis. The average cost (direct and indirect) per case for the entire sample is $2,683. The estimated total cost for the sample (145 cases) is approximately $370,193. Inpatient hospital care is the largest direct medical expense and lost productivity is a major indirect cost to the community. Lessons learned from undertaking this task include: (1) costs incurred are not immediately obvious, (2) without infrastructure in place, tracking costs is difficult, if not impossible, (3) potential for large expenditures is apparent, (4) estimates are consistent with those generated in previous studies, and (5) previous findings of vaccination of certain high-risk populations as a cost-efficient approach is corroborated.     

Illustrating the impact of including future costs in economic evaluations: an application to end-stage renal disease care

There are strong theoretical arguments for including future costs for related and unrelated medical care and non-medical expenditures within economic evaluations. Nevertheless, there is limited data on how inclusion of such costs affects the cost effectiveness of medical interventions in practice. For a low-cost intervention that improves survival in end-stage renal disease (ESRD) patients, we sought to determine how the inclusion of future costs for related medical care (i.e. dialysis and transplantation) and for unrelated medical care and non-medical expenditure would affect the magnitude of the cost per QALY ratio. We performed a cost-utility analysis comparing hemodialysis using a synthetic dialyser (the current treatment of choice in Canada) with the historical gold-standard treatment (use of a cellulose dialyser). We contrasted the results of the analysis including and excluding various measures of future costs. While the inclusion of future costs for unrelated medical care and non-medical expenditures had a significant impact on the cost per QALY ratio, the size of the cost per QALY ratio was most sensitive to inclusion of future costs for related medical care. Our analysis shows that even relatively inexpensive interventions that extend survival of dialysis patients may not be cost-effective since, by extending survival, the extra outpatient dialysis costs that are incurred are large. Inclusion of such costs (which, in and of itself, is methodologically correct) in economic evaluations in this area may mitigate against the acceptance of interventions that are relatively inexpensive themselves but which improve patient survival.     

Development and preliminary evaluation of an early childhood community occupational therapy programme

Community-based occupational therapy must be efficient, effective and of high quality. An innovative community health strategy was developed and implemented to meet the needs of early childhood agencies in the Macarthur community for a more accessible occupational therapy service for preschool children. This paper first describes the needs assessment that underpinned programme development. It then describes the planning and implementation phases of the programme. Finally, the paper outlines the preliminary phase of programme evaluation. This involved a survey of stakeholders to determine their views of the programme and the aspects of the programme that they felt should be included in a later evaluation phase. Stakeholders recommended evaluation of quality and design issues, strengths and weaknesses of programme components, stated aims, use of the programme, and client satisfaction. This programme development and evaluation experience supports the need for systematic, multi-method planning and evaluation strategies in community occupational therapy programmes to ensure effective high quality services.     

Cataract surgery in a community hospital outreach clinic: patients’ costs and satisfaction

A cataract day surgery service for the population of central Norfolk, UK, was provided by the main ophthalmic department in a district general hospital and in an outreach clinic in a community hospital 40 km distant. The outreach clinic aimed to extend the accessibility of this particular service in a rural area where many patients faced long journeys to the main hospital. Samples of 201 patients attending the main hospital for day cataract surgery and 198 patients attending the outreach clinic for the same procedure were identified. Patients were interviewed and given questionnaire forms to establish their general health before the operation, their arrangements to get to hospital and their satisfaction with the clinic and the care they had received. The sample of patients attending the outreach clinic was slightly older, less affluent and in slightly poorer general health than the patients attending the main hospital. The two samples were similar in terms of visual acuity after the operation, complication rates, satisfaction with the outcome of the operation and subsequent use of health services. The journey to hospital was quicker, more convenient and less costly for the outreach clinic patients than the main hospital patients. The net benefit to patients of the outreach clinic was estimated as £39,000 per annum. Satisfaction with administrative matters, facilities at the two clinics and the care received was high in both samples, but patients were significantly more satisfied with arrangements at the smaller outreach clinic. This evidence suggests that an outreach clinic in a small community hospital can provide cataract day surgery under local anaesthesia as effectively as a district centre, at a reduced social cost and with positive social benefits. Further study of heath service costs is vital, but political pressure to acknowledge patient preferences for more local services is growing.     

Public health and economics in tandem: programme budgeting, marginal analysis and priority setting in practice

In the wake of the reforms of the UK National Health Service there has been increased interest in 'getting it right' with respect to priority setting in health care. This article examines the way in which programme budgeting and marginal analysis (PBMA) were introduced into North Mersey. It provides a very practical introduction to the topic and indicates the actual processes that were gone through. It is suggested that, in terms of getting participants in the PBMA exercise to think through what programmes comprise, what they cost, what they are trying to achieve and to focus on relevant possible changes, there was considerable merit in the approach. However there are problems, particularly at the level of determining the costs of different programmes.     

Preventing stroke: a narrative review of community interventions for improving hypertension control in black adults

Incidence rates for stroke and hypertension are higher in black ethnic groups of African descent in the USA and UK than in white groups, suggesting a need for targeted intervention. We conduct a narrative review of published research evidence on community interventions to manage hypertension among black ethnic groups, and explore the concept of cultural sensitivity in these interventions. Data sources comprised computer-aided searches of published studies over the years 1981 to March 2006, on community strategies for improving hypertension control targeting black groups, and further references from these articles. Twenty-seven relevant studies were identified. Health education was associated with improvements in knowledge about hypertension, while education combined with individualised support for patients to self-manage hypertension, including goal setting and monitoring to enhance patient self-management of hypertension, and family support in managing hypertension were associated with reductions in blood pressure levels and improvements in blood pressure control. Collaboration with black communities, using local or minority ethnic staff, conducting preliminary research with target groups to investigate perceptions and canvass ideas for the intervention design were common methods assumed to achieve cultural sensitivity. Studies, however, provided insufficient robust evidence of the effectiveness of these strategies in terms of quantifiable outcomes, although this criterion is contested, with social justice arguments being offered instead. Implicit assumptions about homogeneity and shared interests within the 'community', and representation of 'community' views have implications for the effectiveness of interventions. These findings highlight areas for the future development of interventions to reduce hypertension rates in black groups, and factors that need to be robustly investigated and explicitly addressed in intervention design.     

A questionnaire to measure satisfaction with community services for informal carers of stroke patients: construction and initial piloting

Stroke affects 120 000 people each year in the UK and is the most common cause of adult-onset disability. Most stroke patients are cared for at home by informal carers. Support for these carers is provided by the community services, but although single-item measures have shown that there is a relatively high level of dissatisfaction with those services, there is no specific satisfaction measurement instrument. The present study aimed to construct and initially validate a questionnaire to measure carers' satisfaction with community services for clinical and research purposes. Qualitative interviews with a purposive sample of informal carers of stroke patients identified via stroke unit discharge records gave information about content, context and language. Together with information from the carers' literature, this formed the basis of the questionnaire. A self-completion questionnaire proved unacceptable to carers with a very poor response rate (20%). Face-to-face interviews were more acceptable, with the questionnaire taking approximately 10 minutes to administer. All carers approached agreed to take part and only three carers dropped out from follow up, all because of reasons not related to the study. Initial validity and reliability testing with a sample of 44 carers identified through stroke groups and general practice showed good correlation with a single-item satisfaction measure (RHO = 0.797), test-retest reliability (RHO = 0.885) and inter-rater reliability (RHO = 0.868), and a high degree of internal consistency (Cronbach's alpha = 0.859). Further validation with larger and more diverse groups of informal carers is needed before the questionnaire can be considered to be a robust and reliable tool. Factor analysis revealed seven factors: information about community support and involving the carer; amount, appropriateness and coordination of services; information about stroke; speed of change and concern about the carer; listening to the carer and being heard; problem management; and confidence in and accuracy of information. These factors have marked similarities to those found in the field of patient satisfaction with community services.     

The influence of the quality and quantity of social support in the promotion of community participation following stroke

Background: Community participation for a client who has sustained a stroke often requires the client to make adjustments, adaptations, and compensations for residual impairments or disability following stroke rehabilitation. The ability to make these needed adjustments, adaptations, and compensations often require a client‐centred assistance from an occupational therapist ( Rogers, 2006 ). Assessment of environmental factors, such as social support, is one avenue an occupational therapist may consider in the provision of client‐centred assistance. As such, the purpose of this study was to examine the impact of social support on community participation after stroke. Methods: Ninety‐five stroke survivors were interviewed at home 3 to 6 months postdischarge from a rehabilitation hospital. Multivariate analysis was used to determine the effects of social support on community participation, as measured by the Reintegration to Normal Living Index, following stroke rehabilitation. Quality and quantity of social support were measured using the Social Support Inventory for People with Acquired Disabilities. Results: The quality of social support did not have a greater relationship to community participation than the quantity of social support, as hypothesised. As main effects, both quality (P = 0.03) and quantity (P = 0.004) of social support were found to be significant. Quality and quantity of social support explained 31% and 35% of the variance, respectively, with regard to community participation, indicating moderately strong relationships to the dependent variable. However, the results of bivariate analyses indicate that for people who had sustained a stroke, community participation was more related to their functional limitation (P = 0.001), rather than to the support that was available to them. Conclusions: Assessment and development of social support as a component of occupational therapy intervention may improve the degree of community participation for people with stroke.     

Using programme budgeting and marginal analysis (PBMA) to set priorities: Reflections from a qualitative assessment in an English Primary Care Trust

In England from 2002 to 2013, Primary Care Trusts (PCTs) were responsible for commissioning healthcare for their local populations. The NHS has recently undergone rapid organisational change whereby clinicians have assumed responsibility for local commissioning decisions. This change in commissioning arrangements alongside the current financial pressures facing the NHS provides an impetus for considering the use of technical prioritisation methods to enable the identification of savings without having a detrimental effect on the health of the population. This paper reports on the design and implementation of a technical prioritisation method termed PBMA applied within NHS Plymouth, an English PCT responsible for commissioning services for a population of approximately 270,000. We evaluated the effectiveness of the process, the extent to which it was appropriate for local healthcare commissioning and whether it identified budget savings. Using qualitative research methodology, we found the process produced clear strategic and operational priorities for 2010/11, providing staff with focus and structure, and delivered a substantial planned reduction in hospital activity levels. Participants expressed satisfaction with the process. NHS Plymouth adhered to the PBMA process, although concerns were raised about the evidence for some priorities, decibel rationing, and a lack of robust challenge at priority-setting meetings. Further work is required to enhance participants' understanding of marginal analysis. Participants highlighted several external benefits, particularly in terms of cultural change, and felt the process should encompass the whole local health and social care community. This evaluation indicates that the prioritisation method was effective in producing priorities for NHS Plymouth, and that PBMA provides an appropriate method for allocating resources at a local level. In order for PBMA to identify savings, cultural and structural barriers to disinvestment must be addressed. These findings will interest other healthcare commissioners in developing their own approaches to priority-setting.     

Programme budgeting and marginal analysis: an approach to priority setting in need of refinement

Programme budgeting is enjoying a revival in the British National Health Service primarily because of its recent coupling with marginal analysis. As well as providing a means of mapping activity and expenditure from the institutions providing care to the population receiving it, programme budgeting and marginal analysis aim to assist strategic planning by indicating where net benefits might be increased by reallocating spending within programmes. However, the method to achieve this is not yet sufficiently refined and results to date have been mixed. In particular, the approach to identifying options for evaluation is flawed because of the importance attached to the role of 'expert' groups. A more systematic technique is suggested to overcome present methodological deficiencies.