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Towards Earlier Discharge, Better Outcomes, Lower Cost is a new and valuable study which adds to our understanding of how to better patient outcomes within the budgetary realities of our current healthcare system. This study, undertaken by the ESRI and the RCSI with the support of the Irish Heart Foundation, provides a strong economic justification for policymakers to develop Ireland's community rehabilitation and care services, and equally, shows the potential benefits for patients that can come from healthcare research. This study brought together a range of disciplines and expertise to build on the previous Irish Heart Foundation-supported study, The Cost of Stroke in Ireland, undertaken by researchers at the ESRI and RCSI. We would like to acknowledge the hard work and input of all those involved in the research for this study, especially the researchers in the ESRI, NUIG, RCSI, King's College London and the team in the IHF. We would also like to acknowledge the invaluable guidance of the steering group, many of whom are clinical professionals directly involved in delivering stroke care. We would like to thank the HSE for contributing funding to this research. It is hoped that more research of this nature, which provides an evidence base for the development of Irish healthcare, might be considered in the near future.

This paper undertakes an exploratory examination of the factors that affect where patients receive treatment from Irish acute public hospitals, with particular regard to the influence of patients' public/private status. National univariate statistics indicate that private discharged patients are slightly more likely to be treated outside their county of residence than their public counterparts. A multivariate model necessarily estimated at the county level provides indirect support for this finding for the category of day patients, but not for planned and emergency in-patients. The effects of the other patient characteristics also varied across the three models, although there was consistency in the impact of supply-side factors, such as the type and availability of services. As there appears to be some tendency for private day patients to have a slightly greater propensity to travel for acute public hospital treatment, further research is required to identify the reasons for this, as well as the consequences for public and private patients resident in the source and destination counties.

The impetus for this study arose from the need to upgrade the case mix measure of choice in use at the national level in Ireland. Since 1993, various versions of the DRG grouper supported by the Health Care Financing Administration (HCFA) had been in use in Ireland. With improvements in available data, together with developments in the range and quality of alternative groupers available, it was considered timely to test performance of the alternative options on discharge abstract data for Irish hospitals. The groupers selected for testing included four versions of the Australian Refined (AR) DRGs, the AP DRGs (V18.0), CMS DRGs (V20) and IR DRGs (V1.2). Results for the HCFA DRGS (V16.0) were also included for purposes of comparison. The empirical analysis ranked the AR DRG Groupers highly relative to the alternatives. Additional factors favouring the AR DRG series of Groupers are the fact that they are the more widely used internationally, are updated regularly and supported by Australian government agencies. More support and training opportunities are also available for the use of these Groupers. Given these factors, together with the fact that the ICD-10-AM morbidity coding system is used in Ireland, the AR DRG classification system was recommended as the best option for use at the national level in Ireland.

The public/private mix in Irish health care is nowhere more evident than in the acute hospital system where both public and private patients can be treated in public hospitals by the same consultant. By undertaking new analyses of data from the Hospital In-Patient Enquiry Scheme, this study investigates this public/private mix and its impact on utilisation of hospital services. Demand- and supply-side factors were both found to be statistically significant in explaining the ratio of private to public discharges across hospitals and over time. Private discharges are found to have higher levels of utilisation of surgical procedures, even though the level of comorbidity did not appear to be any greater for this group. The analysis also found that 'excess utilisation' of public hospital facilities by private discharges in particular hospitals increased over the time period of the study. Despite limitations of available data and methods, this study provides useful insights into the factors driving private and public utilisation in the acute public hospital system in Ireland.

Hospital services in Ireland have developed into a complex mixture of public and private provision with private patients being treated in public as well as private hospitals. This interweaving of public and private medicine is driven to a large extent by the large proportion of the population covered by health insurance which has grown from 4% in 1960 to over 50% by 2004. This situation has led to concerns that hospital care is not available to all on the basis of need alone but is substantially influenced by personal circumstances. Previous research on Irish hospitals found that utilisation was neutral across the income distribution controlling for health status – i.e., there was essentially equal treatment for equal need irrespective of income. It could be argued however that these analyses did not properly control for health status as those in lower income groups can be shown to have a lower health status within the same response categories within social surveys. Similarly, previous research has also assumed that treatment costs were identical across groups. In this paper we derive a new measure of health – the ‘Ill Health Index’ using three different health indicators and obtain information on differential costs of treatment across groups. We find that both those with medical insurance and those with medical cards are more likely to use hospital services. The costs of these services are also significantly higher for these groups. Comparison of measures of equity for inpatient utilisation and inpatient costs shows that costs are more pro-poor, but a decomposition of the distribution of hospital costs standardising for health needs shows that higher income groups actually use hospital services more and cost more for the same level of health than lower income groups.

Read before the Society, 28 May 1981, This paper is intended to stand as part of the growing literature on income distribution in the Republic of Ireland. Specifically, it builds on previous work concerned with the description and analysis of the impact of state taxation and transfer payments on that distribution. The focus, therefore, is on the comparison of direct income with disposable income, the difference reflecting the net effect of state policy. Along with that focus, we share with our predecessors a common data source: the 1973 Household Budget Survey. The use of that source, which is primarily designed to collect data on household expenditure, imposes certain limitations and difficulties, which we share with earlier studies. These will be discussed in the appropriate sections of the paper.