Translating policy into practice: a case study in the secondary prevention of coronary heart disease

Background This paper focuses on the relationships between health ‘policy’ as it is embodied in official documentation, and health ‘practice’ as reported and reflected on in the talk of policy‐makers, health professionals and patients. The specific context for the study involves a comparison of policies relating to the secondary prevention of coronary heart disease (CHD) in the two jurisdictions of Ireland – involving as they do a predominantly state funded (National Health Service) system in the north and a mixed health‐care economy in the south. The key question is to determine how the detail of health policy as contained in policy documents connects to and gets translated into practice and action. Methods The data sources for the study include relevant health‐care policy documents (N = 5) and progress reports (N = 6) in the two Irish jurisdictions, and semi‐structured interviews with a range of policy‐makers (N = 28), practice nurses (14), general practitioners (12) and patients (13) to explore their awareness of the documents’ contents and how they saw the impact of ‘policy’ on primary care practice. Results The findings suggest that although strategic policy documents can be useful for highlighting and channelling attention to health issues that require concerted action, they have little impact on what either professionals or lay people do. Conclusion To influence the latter and to encourage a systematic approach to the delivery of health care it seems likely that contractual arrangements – specifying tasks to be undertaken and methods for monitoring and reporting on activity – are required.     

Modelled economic evaluation of a virtual emergency department in Victoria

Objective

Virtual ED (VED) can potentially alleviate ED overcrowding which has been a public health challenge. The aim of the present study was to conduct a return-on-investment analysis of a VED programme developed in response to changing healthcare needs in Australia.

Methods

An economic model was developed based on initial patient outcome data to assess the healthcare costs, potential costs saved and return on investment (ROI) from the VED. The VED programme operating as part of Alfred Health Emergency Services. The participants were the first 188 patients accessing the Alfred Health VED. VED is the delivery of emergency assessment and management of specific patients virtually via audio-visual teleconferencing. ROI ratios that compare cost savings with intervention costs.

Results

The mean total operational cost of VED for 79 days for 188 patients was A$344 117 (95% uncertainty interval [UI] $296 800–$392 088). The VED led to a potential A$286 779 (95% UI $241 688–$330 568) healthcare cost saving from reductions in emergency visits and A$97 569 (95% UI $74 233–$123 117) cost saving in ambulance services. The ROI ratio was estimated at 1.12 (95% UI 0.96–1.32).

Conclusions

The VED was cost neutral in a conservatively modelled scenario but promising if any hospital admission could be saved. Ongoing research examining a larger cohort with community follow up is required to confirm this promising result.     

Gender, oestrogen, hormone replacement and age-related macular degeneration: Results from the Blue Mountains Eye Study

Purpose: To determine whether females have a higher age-specific age-related maculopathy prevalence than males; whether there is an increased risk of age-related macular degeneration (AMD) with early menopause; and whether there is a decreased risk of AMD with use of hormone replacement therapy (HRX). Methods: Pooled data from three study populations that have used similar AMD diagnostic criteria were used to answer the first hypothesis: the Beaver Dam Eye Study (BDES), the Rotterdam study of the elderly, and the Blue Mountains Eye Study (BMES). The BMES population was used to answer the second and third hypotheses. This population included residents aged 49 or older with 2072 women participating, of whom 1899 postmenopausal women answered questions about menopause, menarche and HRT AMD was diagnosed from graded retinal photographs using modified international criteria. Results: The overall pooled odds ratio (OR) for association between sex and AMD revealed a significant increase in AMD prevalence among females compared with males, adjusting for 10-year age categories, OR = 1. 15 (1. 10-1.21), with no significant heterogeneity between studies. A significant decrease in the odds of early AMD with increasing years from menarche to menopause was observed. Conclusions: The results suggest that females may have a higher risk of AMD. The significant decrease in early AMD with increasing years from menarche to menopause supports the concept that a shorter duration of oestrogen production may increase risk of AMD.