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Summary Background Econometric techniques have been used to examine the relationship between costs of provision, case mix and unit size for health care providers. Estimation of cost functions in a health care context is complicated by poor understanding of the underlying production relationship and the constraints under which production takes place. Different results and policy implications can follow from different model specifications. This underscores the need for care in the construction of such functions and the interpretation of their results. Methods Cost and activity data from a study of neonatal care for an English Regional Health Authority are re-examined. Cost functions are estimated using alternative functional forms, and average cost per day is estimated and compared for two of these functions [one produced by Fordham era/. (J Publ Hlth Med 1992; 14(2): 127-130) and the other based more explicitly in economic and econometric theory]. Results It is shown that estimates of average cost per day are sensitive to model specification. Such are the differences in cost that significantly different policy implications could follow from the different models. Conclusion We conclude that care must be taken in the construction and estimation of cost functions and that the assumptions upon which they rest be made explicit so that results can be properly interpreted.

The prescription of home oxygen cylinders is substantial. This study aimed to establish patient's current use of short burst oxygen therapy in chronic obstructive pulmonary disease (COPD) and to examine potential cost savings if cylinder use had been replaced by a concentrator. An interviewer-administered questionnaire was completed by 100 patients currently receiving short burst oxygen therapy. Patients reported that they used their oxygen before exercise/activity (26%), during exercise (19%), after exercise/activity (87%) and at rest (46%) and mostly for the relief of symptomatic breathlessness. The length of time [mean (SD)] patients had oxygen at home was 27.42 (29.31) months. Of those patients using cylinders, savings could have been made by transferring from cylinders to concentrators. While withdrawal of oxygen may be difficult, an oxygen assessment service could ensure that future prescription is aimed at those who benefit and is delivered by the most cost-effective method.

Background An ageing population leads to increasing prevalence of age-related chronic conditions that present challenges to the health-care services. Despite this, in countries including Ireland, little is known about the health-care impact of conditions such as osteoarthritis or rheumatoid arthritis amongst older adults. Methods A series of count models are developed to investigate the incremental health-care usage of individuals with either osteoarthritis or rheumatoid arthritis on the use of general practitioners (GP) services, outpatients’ services, accident and emergency visits and inpatient nights. Results Both types of arthritic conditions lead to increased usage of GP and outpatients’ services but not other hospital services. Differences in entitlements to care, as captured by the presence of a medical card in Ireland, lead to different health-care usage among arthritis sufferers. Translating the additional utilization into cost suggests a combined incremental annual cost of both types of arthritis of E13.6 million. Conclusions Osteoarthritis and rheumatoid arthritis present challenges to health-care services in the context of an ageing population. In the case of Ireland the burden falls predominantly on primary health-care and outpatient services. Within the context of changing health-care service provision in Ireland, the results of this study have implications for future planning of service delivery.

Patients with inflammatory bowel disease who do not respond to steroid therapy often require treatment with immunomodulators in an attempt to achieve a response and maintain remission. However, a major concern and controversy is whether these treatments are putting the patients at a significantly increased risk of developing lymphomas. This case reports a patient with severe ulcerative colitis who had been previously treated with azathioprine and infliximab, and subsequently developed diffuse large B-cell colonic lymphoma.

Background In Europe, overweight and obesity have increased rapidly. Concern about this led to a collaborative study (2011-2012) to estimate the total costs of overweight/obesity to the island of Ireland. A component of that work involved analysis, for the Republic of Ireland (ROI), of the impact of claims for sickness benefit attributable to overweight or obesity, on absence from work, and the associated productivity losses, and on the social welfare bill. Methods Analysis was performed on a dataset from the ROI’s Department …

Background\ud There is limited knowledge of the extent of or factors underlying inequalities in uptake of childhood vaccination in Ireland. This paper aims to measure and decompose socioeconomic inequalities in childhood vaccination in the Republic of Ireland.\ud \ud Methods\ud The analysis was performed using data from the first wave of the Growing Up in Ireland survey, a nationally representative survey of the carers of over 11,000 nine-month old babies collected in 2008 and 2009. Multivariate analysis was conducted to explore the child and parental factors, including socioeconomic factors that were associated with non-vaccination of children. A concentration index was calculated to measure inequality in childhood vaccination. Subsequent decomposition analysis identified key factors underpinning observed inequalities.\ud \ud Results\ud Overall the results confirm a strong socioeconomic gradient in childhood vaccination in the Republic of Ireland. Concentration indices of vaccination (CI = −0.19) show a substantial pro-rich gradient. Results from the decomposition analysis suggest that a substantial proportion of the inequality is explained by household level variables such as socioeconomic status, household structure, income and entitlement to publicly funded care (29.9%, 24% 30.6% and 12.9% respectively). Substantial differences are also observed between children of Irish mothers and immigrant mothers from developing countries.\ud \ud Conclusions\ud Vaccination was less likely in lower than in higher income households. Access to publicly funded services was an important factor in explaining inequalities.

Background Gestational diabetes mellitus (GDM) is a risk factor for the development of type 2 diabetes. Lifestyle intervention can prevent progression to type 2 diabetes in high risk populations. We designed a randomised controlled trial (RCT) to evaluate the effectiveness of an established lifestyle intervention compared to standard care for delaying diabetes onset in European women with recent GDM. Recruitment into the RCT was more challenging than anticipated with only 89 of 410 (22%) women agreeing to participate. This paper identifies factors that could enhance participation of the target population in future interventions. Methods We hypothesised that women who agreed to participate would have higher diabetes risk profiles than those who declined, and secondly that it would be possible to predict participation on the bases of those risk factors. To test our hypothesis, we identified the subset of women for whom we had comprehensive data on diabetes risks factors 3-5?years following GDM, reducing the sample to 43 participants and 73 decliners. We considered established diabetes risk factors: smoking, daily fruit and vegetable intake, participation in exercise, family history of diabetes, glucose values and BMI scores on post-partum re-screens, use of insulin during pregnancy, and age at delivery. We also analysed narrative data from 156 decliners to further understand barriers to and facilitators of participation. Results Two factors differentiated participants and decliners: age at delivery (with women older than 34 years being more likely to participate) and insulin use during pregnancy (with women requiring the use of insulin in pregnancy less likely to participate). Binary logistic regression confirmed that insulin use negatively affected the odds of participation. The most significant barriers to participation included the accessibility, affordability and practicality of the intervention. Conclusions Women with recent GDM face multiple barriers to lifestyle change. Intervention designers should consider: (i) the practicalities of participation for this population, (ii) research designs that capitalise on motivational differences between participants, (iii) alleviating concerns about long-term diabetes management. We hope this work will support future researchers in developing interventions that are more relevant, effective and successful in recruiting the desired population. Trial registration Current Controlled Trials ISRCTN41202110 © 2014 Infanti et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

The political context within which Northern Irelands integrated health and social care system operates has changed since the establishment of a devolved administration (the Northern Ireland Assembly, set up in 1998 but suspended between 2002 and 2007). A locally elected Health Minister now leads the publicly financed system and has considerable power to set policy and, in principle, to determine the operation of other health and social care bodies. The system underwent major reform following the passing of the Health and Social Care (Reform) Act (Northern Ireland) in 2009. The reform maintained the quasi purchaser provider split already in place but reduced the number and increased the size of many of the bodies involved in purchasing (known locally as commissioning) and delivering services. Government policy has generally placed greater emphasis on consultation and cooperation among health and social care bodies (including the department, commissioners and care providers) than on competition. The small size of the population (1.8 million) and Northern Irelands geographical isolation from the rest of the United Kingdom provide a rationale for eschewing a more competitive model. Without competition, effective control over the system requires information and transparency to ensure provider challenge, and a body outside the system to hold it to account. The restoration of the locally elected Assembly in 2007 has created such a body, but it remains to be seen how effectively it will exercise accountability.

In this article we compare the pattern of service utilization in the period preceding the health-care reforms introduced by New Labour with service utilization following the refoms. Data from the 1997 and 2003 waves of the British Household Panel Survey are used to estimate a series of utilization functions. These show that GP utilization overall fell, for women more than men and for the sick more than others. The results suggest that GPs responded to the changing context the reforms created but there are different interpretations of that response. They support the contention that GPs devoted greater attention to preventative services post-reform than had previously been the case. They are also consistent with the contention that GPs responded less directly to the needs of their patients, either because they became more sophisticated in interpreting those needs or conscious of the increased opportunity costs of responding to them.

Objective To investigate the effects of two monetary incentives on response rates to postal questionnaires from primary care physicians (PCPs). Study Design and Setting The PCPs were randomized into three arms ( n = 550 per arm), namely (1) €5 sent with the questionnaire (cash); (2) entry into a draw on return of completed questionnaire (prize); or (3) no incentive. Effects of incentives on response rates and item nonresponse were examined, as was cost-effectiveness. Results Response rates were significantly higher in the cash (66.1%; 95% confidence interval [CI]: 61.9, 70.4%) and prize arms (44.8%; 95% CI: 40.1, 49.3%) compared with the no-incentive arm (39.9%; 95% CI: 35.4, 44.3%). Adjusted relative risk of response was 1.17 (95% CI: 1.02, 1.35) and 1.68 (95% CI: 1.48, 1.91) in the prize and cash arms, respectively, compared with the no-incentive group. Costs per completed questionnaire were €9.85, €11.15, and €6.31 for the cash, prize, and no-incentive arms, respectively. Compared with the no-incentive arm, costs per additional questionnaire returned in the cash and prize arms were €14.72 and €37.20, respectively. Conclusion Both a modest cash incentive and entry into a prize draw were effective in increasing response rates. The cash incentive was most effective and the most cost-effective. Where it is important to maximize response, a modest cash incentive may be cost-effective.

OBJECTIVE To explore the independent effects of gestational diabetes mellitus (GDM) on maternity care and costs. RESEARCH DESIGN AND METHODS Estimates for maternity care resource activity and costs for 4,372 women, of whom 354 (8.1%) were diagnosed with GDM, were generated from data from the Atlantic Diabetes in Pregnancy (ATLANTIC DIP) database. Multivariate regression analysis was applied to explore the effects of GDM on 1) mode of delivery, 2) neonatal unit admission, and 3) maternity care cost, while controlling for a range of other demographic and clinical variables. RESULTS Women with a diagnosis of GDM had significantly higher levels of emergency caesarean section (odds ratio [OR] 1.75 [95% CI 1.08–2.81]), their infants had significantly higher levels of neonatal unit admission (3.14 [2.27–4.34]), and costs of care were 34% greater (25–43) than in women without GDM. Other variables that significantly increased costs were weight, age, primiparity, and premature delivery. CONCLUSIONS GDM plays an independent role in explaining variations in rates of emergency caesarean section, neonatal unit admission, and costs of care, placing a substantial economic burden on maternity care services. Interventions that prevent the onset of GDM have the potential to yield substantial economic and clinical benefits.

Introduction Much of the economic cost associated with severe asthma is related to the treatment of comorbidities, several of which arise from systemic steroid exposure related to asthma management. However these comorbidities may not progress equally across age-groups and genders following systemic steroid exposure. Aim To examine the relationship between age-groups and gender in relation to prevalence of steroid induced comorbidity and the associated costs. Methods Data for a cohort of 808 patients with severe asthma (SA) matched by age and sex with a cohort of 3,975 patients with a diagnosis of mild asthma and 2,412 non-asthma patients with a diagnosis of rhinitis were extracted from the Optimum Patient Care Research Database (OPCRD). Consultation data were used to identify comorbidities and conditional logistic regression analysis provided odds ratios (95% CI’s) for comorbidity risk between cohorts by age-group and gender. Prescription data for individual comorbidities was costed using Prescription Cost Analysis data from Northern Ireland and regressed upon cohort, age and gender. Results Results presented below focus on a comparison between the non-asthma and severe asthma cohorts. Compared to older patients, younger patients in the SA cohort show significantly higher odds ratios relative to the non-asthma cohort for many comorbidities (Table 1). Apart from chronic kidney disease, hypercholesterolemia, osteoporosis and osteopenia, males with SA have higher odds ratios for all other comorbidities listed in Table 1 relative to non-asthma patients than females with SA. Upon examination of costs for individual comorbidities, males cost more than females for type II diabetes, hypertension, psychiatric disorders, while the opposite was observed for osteoporosis and osteopenia. Significant linear and non-linear increasing relationships were observed across age for costs related to type II diabetes, hypertension, hypercholesterolemia, dyspeptic disorders, cardiovascular disease, osteoporosis and osteopenia. Furthermore cost differentials for age and gender exhibited varying relationships across morbidities. Conclusions The odds of having many steroid-induced comorbidities are higher among younger persons; differences between genders are also evident. While patients’ with SA cost significantly more than patients without steroid exposure or with mild steroid exposure, the distribution of the cost across age and gender varies across comorbidities.

Breast cancer screening is an integral part of the cancer control strategies of many developed economies. In Britain individuals screened in a given year are re-called every three years unless results indicate a need for more immediate investigation. This pattern may create a legacy arising from past decisions, a legacy that should be considered when examining current decisions. In this paper we use a balanced panel drawn from the British Household Panel Survey of 1997 women over an 18 year period to examine variations in uptake. A dynamic random effects probit model is used to control for unobserved heterogeneity and the legacy of previous decisions. As might be expected women to whom universal screening is offered are more likely to screen than others. Changes during the study period in the eligible age range saw an increase in uptake among the age group to whom the programme was extended but not among other groups. Past screening behaviour was found to be a significant predictor of current behaviour. Failure to account for past choices may result in model mis-specification and a failure to develop policies aimed at promoting initial engagement that may compromise the screening programme. Income was not found to be a significant determinant of uptake.

Objectives Prostate specific antigen (PSA) testing as a part of a prostate cancer control strategy is the subject of much debate. This paper examines variations in the uptake of PSA testing across Europe and the role of individual and contextual variables in explaining this variation. Methods Data were taken from Eurobarometer 66.2 “Health in the European Union” 2006 on self-reported uptake of screening. Data related to men across the EU-27 and Croatia, aged 40 and over (N = 6986). A logistic regression analysis examines the role of individual characteristics across and within the countries. Results A range of individual characteristics were found to be statistically significant predictors of uptake including education, marital status, and smoking status. Socio-economic status (SES) was also a statistically significant predictor of the likelihood of screening. Variation across countries in uptake was evident; importantly a significant role was accorded primary care in explaining variation in uptake. Conclusion Uptake of PSA testing varies considerably within and across European countries. Differences within states relate to the characteristics of individuals offered tests and differences between states, to the system of primary care in operation. Given the significant welfare losses implicit in the evident variations the role of primary care warrants further investigation.

Background Studies investigating investment in health across the life course are lacking. The aim of this study was to examine investment in dental health across adolescence. Methods Changes in dental health investment, as measured by dental registration (months) between when adolescents were aged 11/12 years compared to when they were 15/16-years-old, were investigated using ordinary least squares (OLS) regressions. Adolescents aged 11 or 12 years in April 2003 in the Northern Ireland Longitudinal Study were included (n = 13,564). The overall change in registration and changes according to socio-economic status, highest educational attainment of household reference person, parental marital status, as well as the individuals' gender and number of siblings were examined. Within variable disparities at both age groups were also investigated. Results Average number of months registered with a dentist fell from 8.14 months (11/12 years old) to 7.38 months (15/16 years old) (p < 0.001). No gender disparities existed when adolescents were aged 11/12 years but when adolescents were 15/16 years old, females had significantly higher registration than males (8.72 months: 8.20 months; p < 0.001). Conclusions During the transition from childhood to adulthood, an individual's dental health may suffer as a result of a decline in registration rates with a dentist. This risk is likely to be greater among males than females. The role of children's services within dentistry should be reviewed.

Background: Paramilitary punishment beatings are a common occurrence in Northern Ireland. Little is known about the costs such attacks impose on the health service. Methods: Data was collected retrospectively on victims treated by Northern Ireland's regional specialist orthopaedics unit. Data related to all victims treated in the unit between January 1999 and May 2000. Results: Average inpatient care costs were £2010 ($2914). There was no significant difference in these between patients who were shot and those who were beaten. Conclusion: Punishment beatings present a small but significant cost burden to the health service. A fuller understanding of them from a health care perspective is warranted. Received 15 August 2000. Accepted 9 January 2001.

Screening is seen by many as a key element in cancer control strategies. Differences in uptake of screening related to socio-economic status exist and may contribute to differences in morbidity and mortality across socio-economic groups. Although a number of factors are likely to underlie differential uptake, differential access to subsequent diagnostic tests and/or treatment may have a pivotal role. This study examines differences in the uptake of cancer screening in Ireland related to socio-economic status. Data were extracted from SLÁN 2007 concerning uptake of breast, cervical, colorectal and prostate cancer screening in the preceding 12 months. Concentration indices were calculated and decomposed. Particular emphasis was placed in the decomposition upon the impact of private health insurance, evidenced in other work to impact on access to care within the mixed public-private Irish health system. This study found that significant differences related to socio-economic status exist with respect to uptake of cancer screening and that the main determinant of difference for breast, colorectal and prostate cancer screening was possession of private insurance. This may have profound implications for the design of cancer control strategies in countries where private insurance has a significant role, even where screening services are publicly funded and population based.

Objectives\ud To investigate differences in participation with breast and cervical cancer screening related to individual socio-economic characteristics, across population-based versus opportunistic screening programmes.\ud \ud Methods\ud Data from Eurobarometer 66.2 “Health in the European Union” 2006 on self-reported breast and cervical cancer screening participation in the preceding 12 months within the EU 15 was obtained The sample was restricted to those eligible for screening based on the screening age within each country. Observations for 2214 and 5025 individuals respectively for breast and cervical cancer screening were available. Data on marital status, self-reported health, socio-economic group and years of education were also available. Screening programmes were categorised as population-based or opportunistic and logistic regression analysis used to examine the relationship between participation, individual characteristics and programme type.\ud \ud Results\ud Differences in participation related to socio-economic status were observed in opportunistic screening programmes for breast cancer (OR = 0.63* and OR = 0.51**) and cervical cancer (OR = 0.75** and OR = 0.64**). Differences related to socio-economic characteristics were not found with respect to participation in population-based programmes.\ud \ud Conclusions\ud In opportunistic programmes, differences in participation across socio-economic groups are evident in respect of both breast and cervical cancer screening. These differences may have implications for treatment and outcomes across socio-economic groups. Such differences were not evident in population-based programmes.

Objective(s) To evaluate the clinical effectiveness and cost-effectiveness of a range of diagnostic strategies for investigating patients with unilateral hearing loss and/or tinnitus, with a view to confirming or eliminating a diagnosis of acoustic neuroma, and to describe the natural history of acoustic neuroma. Data sources Major electronic databases were searched from January 1980 to August 2008. Review methods Selected studies were assessed and subjected to data extraction and quality assessment using standard methods. Results Studies comparing auditory brainstem response (ABR) with magnetic resonance (MR) imaging were highly heterogeneous. ABR has high sensitivity compared with MR imaging for acoustic neuromas greater than 1 cm in size but not for smaller neuromas. The sensitivities of T2-weighted (T2W) and T2-star-weighted (T2*W) imaging strategies compared with gadolinium-enhanced T1-weighted (GdT1W) MR imaging (gold standard) were high and relatively homogeneous. The specificity of T2W and T2*W studies ranged from 90% to 100% and from 86% to 99% respectively. The review of cost-effectiveness showed that GdT1W MR imaging immediately or in conjunction with ABR appears to be more cost-effective than 'traditional' protocols; ABR/GdT1W MR imaging protocols were more cost-effective than going directly to GdT1W MR imaging. Non-contrast-enhanced MR imaging was found to be a more cost-effective test for acoustic neuroma than GdT1W MR imaging. The incidence of acoustic neuroma has increased over the last 30 years, with the median age at diagnosis remaining at 55 years. Most patients present with insidious symptoms of unilateral hearing impairment, tinnitus and/or vertigo. The pattern and rate of growth of acoustic neuroma are highly variable and currently unpredictable. At least 50% of tumours do not grow, at least for some years after diagnosis. Some studies have found large initial size to be a determinant of later growth, with the opposite also being reported. The mean growth rate for all tumours varies between 1 and 2 mm/year, with a rate of 2-4 mm/year for only those that grow; however, there are cases with significant regression (5%) or exceptional growth (which may exceed 18 mm/year). Conclusions The majority of the evidence reviewed was poorly reported and there is therefore an inherent risk of bias. Given the recent improvement in resolution and reduction in cost of MR imaging, ABR can no longer be considered appropriate as the primary test used to screen for acoustic neuroma. T2W or T2*W sequences enable accurate evaluation of the VIIIth and VIIth cranial nerves within the cerebellopontine angle and internal auditory canal as well as evaluation of the cochlea and labyrinth, and inclusion of GdT1W sequences is unlikely to contribute information that would alter patient management in the screening population. The quality of the imaging chain and experience of the reporting radiologist are key factors determining the efficacy of a non-contrast screening strategy. Based on a cost-effectiveness model developed to reflect UK practice it was concluded that a diagnostic algorithm that deploys non-contrast MR imaging as an initial imaging screen in the investigation of acoustic neuroma is less costly than and likely to be as effective as available contrast MR imaging.

To estimate the effect of a consultation charge on the health-seeking behaviour of patients.Cross-sectional survey of patients carried out in Northern Ireland, where services are free at the point of delivery, and the Republic of Ireland, where 70% of the population are charged a consultation fee to see the general practitioner (GP).There were 11 870 respondents to the survey (response rate 52%). In the Republic of Ireland, 18.9% of patients (4.4% of non-paying patients and 26.3% of paying patients) had a medical problem in the previous year but had not consulted the doctor because of cost; this compares with only 1.8% of patients in Northern Ireland. Because those in the Republic of Ireland on low income are entitled to free care, the effects of the consultation charge were most marked in the middle of the income distribution, with such patients being over four times as likely to have been deterred as those in the most affluent group. However, amongst paying patients, it was the poorest and those with the worst health who were most affected. Compared to the most affluent patients and those without depression, the likelihood of not having seen the GP due to cost was 6.75 (95% confidence interval [CI] 3.79, 11.09) for the poorest patients and 2.01 (95% CI 1.53, 2.52) for those with depression.Even in countries with exemptions for the poor and more vulnerable, a consultation charge can deter a large proportion of poorer and less healthy patients from seeing their GP.

Objectives: Most Organisation for Economic Co-operation and Development (OECD) countries have introduced cost-sharing. This study compares the views of patients who are used to a service that is free at the point of delivery with those who are used to a system where 70% of patients pay for consultations. Methods: Secondary analysis of survey data from a random sample of 11,870 patients in Northern Ireland and the Republic of Ireland. Results: A 52% response rate was achieved, though respondents were representative of the two populations. Attitudes generally reflected the national status quo with little support for co-payments where there was currently no charging, but broad support where charging was established. Charging for missed appointments would be supported where there were delays in getting an appointment. Conclusions: More research is needed to understand what underlies support for, or opposition to, charges. However, it is apparent that patients' opinions need to be considered when formulating health care policy.

Objective: To examine the determinants of formal and informal care utilisation amongst persons with AMD. Design: Cross sectional hospital based study. Setting: Hospital eye clinic in Northern Ireland. Participants: 284 persons aged 50 years and above. Main outcome measures: Participants were asked questions about their care, living arrangements, eyesight-related ability to self-care, and eyesight- related need to be more careful whilst undertaking everyday tasks. Results: The percentage of older persons receiving formal and informal care rose with the level of visual impairment. 34.9% and 37.3% of those with no visual impairment received formal and informal care respectively compared with 51.6% and 69.9% of those with moderate visual impairment and 55.6% and 88.9% of those with severe visual impairment. Three factors - age, best corrected distance visual acuity in the better eye, and living alone - were significant predictors (p < 0.05) of care utilisation. The likelihood of a person utilising formal care rose with increasing age, severity of visual impairment and living alone. There is an approximate one-to-one trade-off between age and visual acuity such that a difference in one line of vision is equivalent to approximately one year of life to the affected individual in terms of its impact on the probability of care utilisation. Conclusions: Care utilization is predicted by age, visual acuity in the better eye, and living arrangement. These findings question the validity of the current practice of defining the need for statutory services on the basis of visual acuity alone. These data may have implications for cost utility analyses of new therapeutic developments in macular degeneration.

Introduction Patients with severe asthma are estimated to comprise 5–10% of the total asthma population but contribute disproportionately to the overall burden of disease. A growing body of evidence exists that implicates steroid exposure in morbidity and healthcare costs among this group. Aim This study sought to quantify the additional healthcare costs associated with steroid exposure among patients with severe asthma. Methods Data on patients severe asthma (GINA treatment step 5 with ≥4 prescriptions/year oral corticosteroids, n = 808), was obtained from the Optimum Patient Care Research Database (OPCRD) database along with age and gender matched mild/moderate asthma patients (GINA treatment step 2/3, n = 3975) and non-asthmatic controls (rhinitis only, n = 1865) Data included details of all scheduled and unscheduled healthcare consultations and details of prescribed medicines. Data on service use were extracted for the two most recent years for which observations were available. Healthcare contacts were monetised using unit costs extracted from the Personal Social Services Research Unit’s reference costs and for drugs using Prescription Cost Analysis data. All costs were expressed in their 2013 equivalents. Sensitivity analyses related to identification of staff providing specific consultations or activity, and high/low estimates based on assumptions used were produced. Mean high/low healthcare costs over two years by group were estimated and compared as were costs estimated separately for healthcare contacts and prescribed medicines. Results As shown in Table 1 mean per patient drug, healthcare activity and combined drug and activity costs were significantly higher for the severe asthma group relative to the mild/moderate group with asthma and the non-asthma controls in both high and low cost scenarios. The mean difference in combined cost between the severe and non-asthma controls groups was between £5,031 (low cost) and £5,545 (high cost) depending on the cost scenario and £4,098 (low cost) and £4,510 (high cost) compared to the mild asthma group. Conclusions Patients with severe asthma matched by age and gender have significantly greater direct healthcare costs compared to patients with mild/moderate asthma and non-asthmatic subjects.

Introduction Previous research has indicated that pain influences children's daily lives, resulting in absence from school, sleep problems, poor school performance and problems with social activities. Our study aims to characterise the nature, extent, impact and cost of chronic pain among Irish children. Methods and analysis Using cluster-systematic random sampling, primary schools will be invited to participate and 6000 5–12-year-olds asked to complete questionnaires in school classrooms, at time points 1 year apart. Questionnaires will use internationally valid psychometric measures to assess a range of quality of life factors and chronic pain indicators among children, with corresponding parental/primary caregiver questions, which will be completed at home. Data will also be gathered on the cost of chronic pain. Space will be given for comments on how pain impacts on participants’ lives and possible coping mechanisms. Ethics and dissemination Ethical approval has been granted by the Research Ethics Committee, National University of Ireland, Galway. Dissemination of results will be via journal articles and conference presentations on the various aspects of the study (ie, prevalence, impact and economic cost of chronic pain among 5–12-year-olds living in Ireland). This research is funded by the Health Research Board of Ireland Interdisciplinary Capacity Enhancement Award (Reference: ICE/2011/19). peer-reviewed

Objectives The increasing prevalence of overweight and obesity worldwide continues to compromise population health and creates a wider societal cost in terms of productivity loss and premature mortality. Despite extensive international literature on the cost of overweight and obesity, findings are inconsistent between Europe and the USA, and particularly within Europe. Studies vary on issues of focus, specific costs and methods. This study aims to estimate the healthcare and productivity costs of overweight and obesity for the island of Ireland in 2009, using both top-down and bottom-up approaches.Methods Costs were estimated across four categories: healthcare utilisation, drug costs, work absenteeism and premature mortality. Healthcare costs were estimated using Population Attributable Fractions (PAFs). PAFs were applied to national cost data for hospital care and drug prescribing. PAFs were also applied to social welfare and national mortality data to estimate productivity costs due to absenteeism and premature mortality.Results The healthcare costs of overweight and obesity in 2009 were estimated at €437 million for the Republic of Ireland (ROI) and €127.41 million for NI. Productivity loss due to overweight and obesity was up to €865 million for ROI and €362 million for NI. The main drivers of healthcare costs are cardiovascular disease, type II diabetes, colon cancer, stroke and gallbladder disease. In terms of absenteeism, low back pain is the main driver in both jurisdictions, and for productivity loss due to premature mortality the primary driver of cost is coronary heart disease.Conclusions The costs are substantial, and urgent public health action is required in Ireland to address the problem of increasing prevalence of overweight and obesity, which if left unchecked will lead to unsustainable cost escalation within the health service and unacceptable societal costs.

A substantial amount of health care resources is allocated within the UK using formulae that relate funding to measures of population need. The aim of this paper is to demonstrate the importance of non-need factors in determining utilisation of services at an individual level and explore the implications inclusion of such factors has in the consideration of equity. In the paper we develop a utility model that accords a role to non-health factors in the determination of service use. A series of functions incorporating non-health factors as explanatory variables in GP utilisation functions are estimated using data from the British Household Panel Survey. The functions are decomposed to ascertain the role of service structure and examine the role of income across the four countries of the UK in explaining utilisation. The implications of our findings for the pursuance of equity in the NHS when individual choice has an explicit role are discussed.

As the population of most developed countries ages so the prevalence of diseases such as age-related macular degeneration (AMD) are likely to increase. To facilitate planning and informed debate regarding making provisions for this disease it is important that we have a clear understanding of the economic impact of visual impairment associated with AMD. In this paper we assess the state of current knowledge based on a review of published evidence in scientific journals. Based on our assessment of the evidence we argue that the paucity of research studies on the subject and wide variation in estimates produced from the few studies available make it difficult to assess with confidence the likely average direct cost-of-illness associated with AMD. We further argue that significant gaps in our understanding of the costs of AMD (particularly in respect of indirect costs) also exist. Current research should be augmented by more comprehensive studies.

p16 is a cyclin-dependent kinase-4 inhibitor that is expressed in a limited range of normal tissues and tumors. In recent years, immunohistochemistry with p16 antibodies has been used as a diagnostic aid in various scenarios in gynecologic pathology. Diffuse (as opposed to focal) positivity with p16 in the cervix can be regarded as a surrogate marker of the presence of high-risk human papillomavirus (HPV). In cervical squamous lesions, p16 is positive in most high-grade cervical intraepithelial neoplasia (CIN) and in some cases of low-grade CIN, usually those associated with high-risk HPV. p16 may be useful to identify small focal high-grade CIN lesions, to distinguish some cases of CIN involving immature metaplastic squamous epithelium from immature metaplastic squamous epithelium not involved by CIN and to distinguish high-grade CIN from benign mimics. Most cervical carcinomas of squamous, glandular, and small cell type are p16-positive. In cervical glandular lesions, p16 is useful, as part of a panel, in the distinction between adenocarcinoma in situ (diffusely positive) and benign mimics, including tuboendometrial metaplasia and endometriosis, which are usually p16-negative or focally positive. p16 may be used, in combination with other markers, to distinguish between a cervical adenocarcinoma (diffuse positivity) and an endometrioid-type endometrial adenocarcinoma (negative or focally positive). Some uterine serous carcinomas are diffusely positive. In the vulva, p16 is positive in HPV-associated vulval intraepithelial neoplasia (VIN) but negative in VIN not associated with HPV. Similarly, HPV-associated invasive squamous carcinomas are p16-positive, whereas the more common non-HPV-associated neoplasms are largely negative or focally positive. In the uterus, p16 positivity is more common and widespread in leiomyosarcomas than leiomyomas, and this may be a useful aid to diagnosis, although problematic uterine smooth muscle neoplasms have not been extensively studied. Metastatic cervical adenocarcinomas in the ovary are usually diffusely p16-positive, and because these may closely mimic a primary ovarian endometrioid or mucinous adenocarcinoma, this may be a valuable diagnostic aid, although p16 expression in primary ovarian adenocarcinomas of these morphologic subtypes has not been widely investigated. Some ovarian serous carcinomas, similar to their uterine counterparts, are p16-positive.

Objectives: To test the reliability of a validated closed-format questionnaire assessing parental views following cochlear implantation of their child. Design: Parents were surveyed using a closed-format questionnaire developed in earlier work. The same parents were surveyed 1 month later and responses compared. Test–retest reliability was thereby assessed. Setting: Tertiary referral Pediatric Cochlear Implant Centre in the UK. Subjects and Methods: The parents of 20 children who had been born deaf or were deafened by age 3 years and who had been implanted for at least 2 years were drawn at random from patient lists. Parents were surveyed using a closed-format questionnaire whose validity had been previously assessed and re-surveyed 1 month later. Responses over time were compared. Results: For the majority of items in the questionnaire, the replication of the item would lead to the same response on at least 95% of occasions. The text of the closed-format questionnaire is reproduced in full. Conclusion: This validated closed-format questionnaire appears to be unique in respect of cochlear implantation, being based explicitly on issues thought important by the parents. The high test–retest reliability indicates that it is capable of eliciting parental views in a meaningful manner. This information that is not currently available by other means can then be used as part of an overall assessment of outcomes, to inform efforts aimed at quality improvement as well as demonstrating accountability to purchasers and policymakers. Moreover, a wider use of this instrument can result in valid comparisons of outcomes among different cochlear implant centres.

Legalisation of assisted suicide presents a dilemma for society. This arises because of a lack of consensus regarding the precedence to be accorded freedom of choice versus the inviolability of human life. Several factors including improvements in medical technology, population ageing and changing perceptions about quality of life serve to make a re-examination of attitudes to this issue appropriate at this time. Within this context, data from the 1983, 1984, 1989 and 1994 British Social Attitudes Surveys (BSAS) were examined. These demonstrate a slight increase in support for physician-assisted suicide (PAS) from around 75% to around 84% over the 11-year period in Britain. A much lower level of support (54%) was recorded in relation to family-assisted suicide (FAS). A logistic regression analysis of data from the 1994 survey was undertaken to establish the relationship between attitudes toward legalisation of PAS and FAS and the characteristics of the respondent. Strength of religious affiliation was found to be a significant determinant of opposition to legalisation of both. Religious denomination was found to be marginally significant in relation to PAS but not FAS. Members of the Church of England, non-Christian faiths and those of no faith were found to be marginally more likely to support legalisation of PAS, than Roman Catholics or those of other Christian faiths. Education, income, sex, marital status, long-standing illness and age were not found to be significant predictors of attitude. In relation to FAS age was also found to be significant predictor of opposition. Findings here suggest that if Britain continues to become a more secularised society, support for legalisation of PAS (and FAS) is likely to increase. As health care costs continue to grow and the ability to extend life (even where the quality of that life may be poor) increases, pressure for legalisation of PAS may increase.

Expenditures on prescribed medicines are significantly higher among those aged 65 years and over than among younger people. As populations in developed countries age so the cost of pharmacological care associated with the older population can be expected to increase. While pharmacological care represents only one component of healthcare, its costs are increasing rapidly because of advances in technology and increasing use. However, such costs should be considered within a context of decreasing disability in the elderly population, improving economic conditions among seniors and the relationship of these costs with those in other aspects of healthcare. Where medications have been demonstrated to be cost-effective, attempts to curtail expenditure growth may prove a false economy resulting in significantly higher growth elsewhere such as in the hospital and long-term care sectors. Policy responses to this issue should encompass the inclusion of elderly patients in clinical trials, the use of evidence-based principles of practice and strategies to ensure that this population obtain maximum benefit from medication through education and counselling.

Objective: To investigate variations in gains in auditory performance in children with cochlear implants. Study Design: The auditory performance of 98 children was measured with the Category of Auditory Performance survey instrument. All data were collected prospectively. Variables used to explain gain in Category of Auditory Performance were age at implantation, sex, the duration of untreated deafness the year in which implantation occurred, health care inputs, and cause of hearing impairment. The data were analyzed by ordered probabilistic regression analysis. Results: Gain in Category of Auditory Performance was observed to be negatively related to age at implantation, the year in which implantation took place, and the number of medical consultations the child received. None of the other variables were significant determinants of gain in Category of Auditory Performance. Conclusion: This study demonstrates the value of examining incremental gain from implantation rather than simply examining outcome levels. It was found that pediatric implantation is subject to diminishing returns. This suggests that further relaxation of entry criteria to implant programs should be undertaken only after careful consideration. The study also confirmed that age at implantation is an important determinant of outcomes. Greater gain in Category of Auditory Performance was experienced by those who underwent implantation at a younger age. This finding has implications for screening, as well as for purchasers and providers of implant services, highlighting the importance of responding in a timely fashion to identified need.

BMC Pharmacology and Toxicology was created from the merger of two journals within the BMC series published by BioMed Central: BMC Pharmacology and BMC Clinical Pharmacology. BMC Pharmacology operated anonymous peer review whereas BMC Clinical Pharmacology operated a fully open peer review policy where the identity of the reviewers was known to the editors, authors and readers. The merged journal also adopted a fully open peer review policy. Two years on we discuss the views and experiences of our Editorial Board Members towards open peer review on this biomedical journal.

Contains fulltext : 137147.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To perform a systematic review of studies that assessed the potential of patient decision support interventions (decision aids) to generate savings. DESIGN: Systematic review. DATA SOURCES: After registration with PROSPERO, we searched 12 databases, from inception to 15 March 2013, using relevant MeSH terms and text words. Included studies were assessed with Cochrane's risk of bias method and Drummond's quality checklist for economic studies. Per patient costs and projected savings associated with introducing patient decision support interventions were calculated, as well as absolute changes in treatment rates after implementation. ELIGIBILITY CRITERIA: Studies were included if they contained quantitative economic data, including savings, spending, costs, cost effectiveness analysis, cost benefit analysis, or resource utilization. We excluded studies that lacked quantitative data on savings, costs, monetary value, and/or resource utilization. RESULTS: After reviewing 1508 citations, we included seven studies with eight analyses. Of these seven studies, four analyses predicted system-wide savings, with two analyses from the same study. The predicted savings range from $8 ( pound5, euro6) to $3068 ( pound1868, euro2243) per patient. Larger savings accompanied reductions in treatment utilization rates. The impact on utilization rates was mixed. Authors used heterogeneous methods to allocate costs and calculate savings. Quality scores were low to moderate (median 4.5, range 0-8 out of 10), and risk of bias across the studies was moderate to high (3.5, range 3-6 out of 6), with studies predicting the most savings having the highest risk of bias. The range of issues identified in the studies included the relative absence of sensitivity analyses, the absence of incremental cost effectiveness ratios, and short time periods. CONCLUSION: Although there is evidence to show that patients choose more conservative approaches when they become better informed, there is insufficient evidence, as yet, to be confident that the implementation of patient decision support interventions leads to system-wide savings. Further work-with sensitivity analyses, longer time horizons, and more contexts-is required to avoid premature or unrealistic expectations that could jeopardize implementation and lead to the loss of already proved benefits. REGISTRATION: PROSPERO registration CRD42012003421.

Objective: To demonstrate the existence of variations in cost-utility associated with indirect costs in paediatric cochlear implantation; to illustrate the implications of this for purchasing decisions and; to posit a potential solution to anomalies in purchasing that may otherwise result when services are publicly funded. Methods: Data was taken from published sources on the cost of implantation, outcomes measured in terms of quality adjusted life years (QALY) and in savings in education costs associated with paediatric cochlear implantation. Cost-utility ratios across education authorities were calculated using a single centre's implantation costs. Results: Variations in savings across education authorities show that the cost per QALY gain associated with paediatric cochlear implantation can vary between approximately $12 000 and $18 000 assuming an exchange rate of $1.45=£1 for the same implant centre. These variations have the potential to produce situations in which less efficient implant centres are preferred by purchasers over more efficient ones or in which candidates with poorer outcomes are selected for funding over candidates with superior outcomes. It is important that savings associated with education be taken into consideration in evaluations intended to inform purchasing decisions regarding implantation. Equally it is important that potentially anomalous decisions be avoided if evaluations are to remain credible. It is argued that this may be achievable if public funding for implantation is determined at a national level and ring-fenced i.e. devoted exclusively to use in cochlear implantation.

This cross-sectional study of 400 sera from a randomly selected adult population in Northern Ireland, using a microimmunofluorescence assay, demonstrated high overall seropositivity (70%) for IgG Chlamydia pneumoniae antibodies in developed populations. Seropositivity was shown to be unrelated to gender, age or smoking but there was an inverse trend between infection and educational level achieved as a measure of socio-economic status. IgG levels were also higher during the winter months suggesting seasonal variation of Chlamydia pneumoniae infection. The high prevalence of evidence of exposure to Chlamydia pneumoniae as described in this study may have implications for prevention of cardiovascular disease if further evidence conclusively determines that infection with this organism is a risk factor for cardiovascular disease.

Asymmetry of information presents major difficulties for the efficient operation of markets in health care. The use of accreditation schemes may reduce these difficulties by enhancing the availability of reliable, accessible information on aspects of service quality considered important by service users and their agents. The UK's Patients' Charter with its associated Charter Marks has the potential to perform such a function in respect of inpatient services. In as much as it refers to aspects of service valued by service users which are specified in contracts by service procurers and appear not to be negatively correlated with other aspects of service quality, it can be seen to provide unambiguous signals of service quality. Given the Charter is currently under review, it seems appropriate that such attributes are borne in mind by policy makers in their deliberations as to its future.

Background Overweight and obesity are increasing in prevalence worldwide In Ireland, their prevalence makes up over 60% of the population. The incidence of many chronic diseases, and some cancers, is increased in those who are overweight and obese. This places pressure on the health service, financially and otherwise. There is also a cost on society in terms of productivity loss. Many countries have studied the costs involved, but as each country has a unique profile of risk prevalence and health service, the costs are country specific. In order to inform prevention policies and ignite political will in the public health battle against obesity, the measurement of direct and indirect costs of overweight and obesity is a useful exercise. This study was a collaborative effort to enumerate these costs for the island of Ireland. Methods A comprehensive literature review was performed examining the international evidence on cost of overweight and obesity. Regression analyses of data from SLAN and TILDA in the Republic of Ireland, and The 2010/11 Health Survey for Northern Ireland were performed to give estimates of direct health care costs in both jurisdictions, and of indirect costs due to absenteeism. In addition, Population Attributable Fractions were applied to hospital activity, drug reimbursement, social welfare and mortality data for both jurisdictions to give additional information where no survey data were available, and to triangulate results. Adjustments were made for inflation and purchasing power parity to allow for the production of an estimate in one currency for a single year. Results The literature review yielded 45 studies and showed heterogeneity of methodology between studies. However, in almost all cases there was a positive correlation between obesity and increased healthcare costs, and indirect costs were in all cases greater than direct costs. The cost of overweight and obesity for the Republic of Ireland was estimated to be €1,166,050,482 and for Northern Ireland it was €510,323,754 for the year 2009. Direct healthcare costs represented 38% of the total, and 2.9% of total healthcare spend in the Republic of Ireland and, in Northern Ireland, 25% of the total and 2.8% of total healthcare spend. Conclusion Urgent public health action is required in Ireland to address the problem of increasing prevalence of overweight and obesity. The cost of associated chronic disease is substantial, and if prevalence rates continue to rise, will cause unsustainable health service cost escalation, and productivity losses to the wider economy.

OBJECTIVE: To establish the effect of health education on the level of distress felt by patients with angina and to compare the results obtained using different measures. DESIGN: Randomised controlled trial of personal health education given every four months. SETTING: Eighteen general practices in the greater Belfast area. SUBJECTS: These comprised 688 patients aged less than 75 years and known to have had angina for at least six months: 342 were randomised to receive education and 346 no education. MAIN OUTCOME MEASURES: These were the Nottingham health profile (NHP), functional limitation profile (FLP), and a simple categorical scale (SCS). RESULTS: The intervention group showed a statistically significant improvement in health relative to the control group in terms of physical mobility and social isolation using the NHP. In terms of overall wellbeing, both the NHP and SCS results showed the intervention group had experienced statistically significant improvements in health relative to the control group. Results obtained using the NHP, FLP, and SCS were found to be correlated regardless of whether weighted or unweighted scores were used. CONCLUSION: The intervention produced a significant improvement in health status. Results from different survey instruments were correlated using both weighted and unweighted scores. An SCS was capable of detecting the improvement in health status.

Objective: To examine the relative cost effectiveness of a range of screening and intervention strategies for preventing coronary heart disease in primary care. Subjects: 7840 patients aged 35-64 years who were participants in a trial of modifying coronary heart disease risk factors in primary care. Design: Effectiveness of interventions assumed and the potential years of life gained estimated from a risk equation calculated from Framingham study data. Main outcome measure: The cost per year of life gained. Results: The most cost effective strategy was minimal screening of blood pressure and personal history of vascular disease, which cost pounds sterling310-pounds sterling930 per year of life gained for men and pounds sterling1100-pounds sterling3460 for women excluding treatment of raised blood pressure. The extra cost per life year gained by adding smoking history to the screening was pounds sterling400-pounds sterling6300 in men. All strategies were more cost effective in men than in women and more cost effective in older age groups. Lipid lowering drugs accounted for at least 70% of the estimated costs of all strategies. Cost effectiveness was greatest when drug treatment was limited to those with cholesterol concentrations above 9.5 mmol/l. Conclusions: Universal screening and intervention strategies are an inefficient approach to reducing the coronary heart disease burden. A basic strategy for screening and intervention, targeted at older men with raised blood pressure and limiting the use of cholesterol lowering drugs to those with very high cholesterol concentrations would be most cost effective. Key messages Key messages The most cost effective strategy is to target patients with raised blood pressure or a history of coronary heart disease Extending the strategy to include other factors increases the cost by variable amounts All prevention strategies are more cost effective in men than in women and in older than younger age groups Drug treatment for patients with high cholesterol concentrations is cost effective, but the incremental cost of extending treatment to lower cholesterol concentrations is high

Background A socio-economic gradient in use of health care has been observed in a number of situations. These have been used to assess the performance of systems as well as frame discussion on system design. Examination of patterns at an aggregate level may mask important differences between types of care that could lead to different policy advice. Aims To identify whether differences in registration and use related to socio-demographic characteristics exist in respect of publicly funded oral health care in Northern Ireland and if so to identify the nature of differences in care. Methods NHS reimbursement data were linked to census and vital statistics data within the Northern Ireland Longitudinal Study. Data cover 28% of the population in Northern Ireland and in this study cover a period from 2003 to 2008. Data for individuals aged 11 or 12 in April 2003 that include registration status, reimbursement on a per item basis, gender, community background, siblings and also the social class and education of household reference person (HRP) were extracted. A series of multivariate analyses were used to examine the relationship between registration and use of care as a function of socio-demographic characteristics. Results A clear socio-economic gradient was evident in respect of registration status. Adolescents whose HRP was long term unemployed or never worked were registered for 6 months (from a maximum of 54) less and consumed 8.3% less expenditure than those whose HRP was professional. While those from lower social backgrounds consumed 24.4% less expenditure on orthodontic services, with respect to extractions and conservative treatment, adolescents whose HRP was long term unemployed or never worked consumed 35.6% and 25.8%, respectively, more expenditure than those whose HRP was professional, other variables controlled for. Conclusions A publicly funded demand led service can produce a pattern of service provision that disproportionately reflects the preferences of the affluent at the expense of the needs of the less affluent. This might be masked by analysis of data at an aggregate level. The pattern of service provision that results may from a societal perspective be neither efficient (cost effective) nor equitable. The disaggregated analysis of registration and utilisation patterns in this study highlights the potential for such distortion where public funds support demand led provision by for profit providers.