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Aims To systematically review the evidence on the costs and cost-effectiveness of self-management support interventions for people with diabetes. Background Self-management support is the provision of education and supportive interventions to increase patients' skills and confidence in managing their health problems, potentially leading to improvements in HbA1c levels in people with diabetes. Methods Randomized controlled trials, observational studies or economic modelling studies were eligible for inclusion in the review. The target population was adults with diabetes. Interventions had to have a substantial component of self-management support and be compared with routine care. Study quality was evaluated using the Consensus on Health Economic Criteria and International Society of Pharmacoeconomic Outcomes Research questionnaires. A narrative review approach was used. Results A total of 16 costing and 21 cost-effectiveness studies of a range of self-management support interventions were identified. There was reasonably consistent evidence across 22 studies evaluating education self-management support programmes suggesting these interventions are cost-effective or superior to usual care. Telemedicine-type interventions were more expensive than usual care and potentially not cost-effective. There was insufficient evidence regarding the other types of self-management interventions, including pharmacist-led and behavioural interventions. The identified studies were predominantly of poor quality, with outcomes based on short-term follow-up data and study designs at high risk of bias. Conclusions Self-management support education programmes may be cost-effective. There was limited evidence regarding other formats of self-management support interventions. The poor quality of many of the studies undermines the evidence base regarding the economic efficiency of self-management support interventions for people with diabetes. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to carry out an economic evaluation of robot-assisted hysterectomy compared with the current standard of care in Ireland. Design Cost-minimisation analysis of robot-assisted hysterectomy compared with a combination of traditional open and conventional laparoscopic surgery. Setting The publicly funded healthcare system in Ireland. Population The target population was women requiring hysterectomy that could be completed using robot-assisted surgery. Methods A simulation-based economic evaluation model including data derived from a systematic review and local databases was used to estimate surgical costs. Main outcome measures Incremental cost of robot-assisted surgery compared to current routine care. Results The incremental cost of robot-assisted hysterectomy is an estimated €3291 (95% confidence interval €2509-€4183) more than the existing mix of open and traditional laparoscopic surgery. The additional cost of robot-assisted surgery is primarily driven by the increased cost of surgical equipment, the robot, maintenance of the robot, and the cost of theatre staff due to longer operative times. The only significant factor reducing the cost of surgery is a shorter hospital stay relative to open surgery. Conclusions Robot-assisted hysterectomy is more costly than the current mix of open and traditional laparoscopic surgery. Without longer-term or functional outcome data, the additional expense associated with robot-assisted hysterectomy may not be justified in a budget-constrained health system. [ABSTRACT FROM AUTHOR]

Background: General practice makes a critical contribution to healthcare in Ireland. However, there is a weak understanding of the general practice workforce in Ireland. Aims: The aim of this study is to estimate the number of general practitioners (GPs) and practice nurses in Ireland. Methods: A variety of data sources was used to corroborate counts of general practitioners and practice nurses. Capture-recapture methods were used to estimate the hidden population of GPs not identified by the databases included. Results: There are 2,954 general practitioners in Ireland, equivalent to 64.4 per 100,000 population. There are 1,700 practice nurses nationally, equivalent to 37.1 per 100,000 persons. There is substantial regional variation in the number of general practitioners and practice nurses per 100,000. To some extent, deficits in one discipline may be counterbalanced by a surplus in the other. Conclusions: In the absence of a centralised register, it is not possible to track the number of GPs or practice nurses working in Ireland at present. This is despite the fact that there are twice as many general practice visits per annum compared to hospital visits. [ABSTRACT FROM AUTHOR]

Background:Rectal bleeding is a recognised early symptom of colorectal cancer. This study aimed to assess the diagnostic accuracy of symptoms, signs and diagnostic tests in patients with rectal bleeding in relation to risk of colorectal cancer in primary care.Methods:Diagnostic accuracy systematic review. Medline (1966 to May 2009), Embase (1988 to May 2009), British Nursing Index (1991 to May 2009) and PsychINFO (1970 to May 2009) were searched. We included cohort studies that assessed the diagnostic utility of rectal bleeding in combination with other symptoms, signs and diagnostic tests in primary care. An eight-point quality assessment tool was produced to assess the quality of included studies. Pooled positive likelihood ratios (PLRs), sensitivities and specificities were calculated.Results:Eight studies incorporating 2323 patients were included. Average weighted prior probability of colorectal cancer was 7.0% (range: 3.3–15.4%, median: 8.1%). Age 60 years (pooled PLR: 2.79, 95% confidence interval (CI) 2.00–3.90), weight loss (pooled PLR: 1.89, 95% CI: 1.03–3.07) and change in bowel habit (pooled PLR: 1.92, 95% CI: 0.54–3.57) raise the probability of colorectal cancer into the range of referral to secondary care but do not conclusively ‘rule in’ the diagnosis. Presence of severe anaemia has the highest diagnostic value (pooled PLR: 3.67, 95% CI: 1.30–10.35), specificity 0.95 (95% CI: 0.93–0.96), but still only generates a post-test probability of 21.6%.Conclusions:In patients with rectal bleeding who present to their general practitioner, additional ‘red flag’ symptoms have modest diagnostic value. These findings have implications in relation to recommendations contained in clinical practice guidelines. [ABSTRACT FROM AUTHOR]

The Hospital Inpatient Enquiry (HIPE) system is an important information source for research and health service planning activities. However, as it was not designed explicitly for these purposes, some limitations exist. To make recommendations that would increase the value of HIPE as a research and planning tool. Experiences of using HIPE for research and planning exercises were analysed so as to identify its limitations and their impact on research and planning. Limitations were identified regarding data quality, policy issues and the general system. To increase the utility of HIPE as a research and planning tool, a number of changes are recommended, including: expanding the system to cover private hospitals and outpatient and emergency services; adopting routine small area and socio-economic coding; adopting unique personal identifiers; publishing regular detailed reports with in-depth analyses; and considering making hospital identifiers available in certain circumstances. [ABSTRACT FROM AUTHOR]

Objective. To study the effect of material deprivation on prescribing trends in primary care, using a locally derived deprivation score. Methods. A retrospective analysis of prescribing trends linked to material deprivation by district electoral division (DED) in the Eastern Region of the General Medical Services in Ireland (population of 334,031) was performed. Standardised prescribing ratios were determined for a number of drug classes, including those that could be used to identify particular diseases for 181,647 patients who were assigned a locally derived material deprivation score. Results. Prescribing rates for a number of medications including anti-asthma, nitrate and benzodiazepine medications increased, whilst the prescribing of other medications such as anti-parkinsonian and antidepressive agents decreased with increasing deprivation. Conclusions. Our results suggest that, even within a population considered to be economically deprived, different levels of deprivation may significantly influence general practitioner prescribing patterns. Within the group of centrally active medications, the prescription of symptomatic medications increased with increasing material deprivation, whilst the prescription of disease-specific medications decreased with increasing material deprivation. [ABSTRACT FROM AUTHOR]

A reply to a letter to the editor in response to the article "Economic evaluation of robotassisted hysterectomy: A costminimisation analysis," published in a pervious issue is presented.

A response from the author of the article "Economic evaluation of robot-assisted hysterectomy: a cost-minimisation analysis" in the 2014 issue.

Objectives Heroin users are at high risk of premature mortality. Despite the evidence supporting methadone maintenance programmes (MMT), methadone itself has been associated with drug-related deaths. This study aims to determine whether people prescribed methadone have an elevated risk of overdose mortality during periods of treatment transition, particularly during treatment initiation. Method Retrospective cohort study of 3162 Scottish people prescribed and dispensed liquid methadone between January 1993 and February 2004. Observation time was defined as a period during methadone treatment or a period of maximum 6 months after leaving treatment. Individual observation time was censored after 6 months off-treatment. A person's observation time started again if they re-entered treatment after an off-treatment period. The main outcome measure was drug-related mortality by means of Cox-proportional hazards models during the 12 years of follow-up. Drug-related deaths occurring during treatment or within 3 days after last methadone prescription were considered as cases “on treatment”. Fatalities occurring 4 days or more after leaving treatment were considered to be drug-related deaths “off treatment”. Results Overall 130 people died, with 51 deaths identified as drug-related deaths (20 off treatment and 31 in treatment). Risk of drug-related mortality was higher during treatment than off treatment (adjusted hazard ratio 11.17, 95% CI 4.51 to 27.64). Inspection of timing of death showed that the risk of drug-related mortality was higher during the initial two weeks of treatment (adjusted hazard ratio 16.93, 95% CI 5.17 to 55.46) compared to the risk of mortality off treatment. Similarly, retention in treatment for more than 3 weeks was associated with increased mortality relative to being off treatment (adjusted hazard ratio 9.97, 95% CI 4.08 to 24.39). In relation to risk of mortality during treatment, being in treatment for 3–10 weeks (adjusted hazard ratio 0.36, 95% CI 0.15 to 0.85) or greater than 10 weeks (adjusted hazard ratio 0.13, 95% CI 0.04 to 0.39) was associated with a reduced risk of mortality compared to the initial two weeks on treatment. These effects were observed after adjusting for all or some of the following covariates; co-prescribing of benzodiazepines, psychiatric admission, number of methadone treatments, overuse of methadone and urine testing, where appropriate. Conclusion Excess mortality risk in the initial two weeks of methadone treatment indicates the need for more care in prescribing and monitoring of methadone when starting or restarting a patient on methadone maintenance therapy. [ABSTRACT FROM AUTHOR]

Objectives Heroin users are at high risk of premature mortality. Despite the evidence supporting methadone maintenance programmes (MMT), methadone itself has been associated with drug-related deaths. This study aims to determine whether people prescribed methadone have an elevated risk of overdose mortality during periods of treatment transition, particularly during treatment initiation. Method Retrospective cohort study of 3162 Scottish people prescribed and dispensed liquid methadone between January 1993 and February 2004. Observation time was defined as a period during methadone treatment or a period of maximum 6 months after leaving treatment. Individual observation time was censored after 6 months off-treatment. A person's observation time started again if they re-entered treatment after an off-treatment period. The main outcome measure was drug-related mortality by means of Cox-proportional hazards models during the 12 years of follow-up. Drug-related deaths occurring during treatment or within 3 days after last methadone prescription were considered as cases “on treatment”. Fatalities occurring 4 days or more after leaving treatment were considered to be drug-related deaths “off treatment”. Results Overall 130 people died, with 51 deaths identified as drug-related deaths (20 off treatment and 31 in treatment). Risk of drug-related mortality was higher during treatment than off treatment (adjusted hazard ratio 11.17, 95% CI 4.51 to 27.64). Inspection of timing of death showed that the risk of drug-related mortality was higher during the initial two weeks of treatment (adjusted hazard ratio 16.93, 95% CI 5.17 to 55.46) compared to the risk of mortality off treatment. Similarly, retention in treatment for more than 3 weeks was associated with increased mortality relative to being off treatment (adjusted hazard ratio 9.97, 95% CI 4.08 to 24.39). In relation to risk of mortality during treatment, being in treatment for 3–10 weeks (adjusted hazard ratio 0.36, 95% CI 0.15 to 0.85) or greater than 10 weeks (adjusted hazard ratio 0.13, 95% CI 0.04 to 0.39) was associated with a reduced risk of mortality compared to the initial two weeks on treatment. These effects were observed after adjusting for all or some of the following covariates; co-prescribing of benzodiazepines, psychiatric admission, number of methadone treatments, overuse of methadone and urine testing, where appropriate. Conclusion Excess mortality risk in the initial two weeks of methadone treatment indicates the need for more care in prescribing and monitoring of methadone when starting or restarting a patient on methadone maintenance therapy. [ABSTRACT FROM PUBLISHER]