A mixed-methods evaluation of novel services for vulnerable patient groups in Ireland

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O'Mahony, Cian
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University College Cork
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Introduction: Rising healthcare costs present a challenge to healthcare systems around the world. In Ireland, healthcare spending accounts for greater than a quarter of government expenditure. Cancer patients and older persons are two patient population groups that account for a large portion of healthcare utilisation and both groups are continuously increasing in number. Safe, cost- effective innovations are needed to provide care for these population groups while maintaining an adequate level of spending. This thesis sought to evaluate novel interventions that target cancer patients and older persons in Ireland, assessing both cost and quality of the interventions. Methods: This thesis examined the cost and quality of the introduction of the novel services in Cancer and Older Person services i.e. Community Oncology Nursing Programme in the West of Ireland, the monitoring of oral anti-cancer therapies (OATs) nationally and the Optimising thERapy to prevent avoidable hospital Admissions in Multi-morbid older people (OPERAM) trial in Cork. These interventions were chosen as examples of recent innovations in the care of vulnerable, costly patient groups. Diverse local, regional and national Irish healthcare settings were evaluated, using a mix of economic evaluation and qualitative principles, as part of this thesis. Methodologies such as literature reviews, economic evaluations (cost-effectiveness analysis and cost comparison analysis), and qualitative analysis (using the thematic analysis) helped provide evidence and inform the recommendations. Results: The full service pathway of cancer care provision in the hospital and community settings were mapped at a high-level. This was the first step of a Time-Driven Activity-Based Costing (TDABC) model of cost evaluation. Both internal and external evaluation of the service was carried out. Inefficiencies were noted in the process flow, although these were unable to be addressed due to financial and time restraints. The cost of providing cancer care in the community, that being in primary care centres or the patient’s own home, were compared to providing the same care in an oncology day ward. Both the Irish health payer and societal perspectives were evaluated. From the healthcare provider perspective, the day-ward was a significantly cheaper option by an average of €17.13 per patient (95% CI €13.72 - €20.54, p<0.001). From the societal perspective, the community option was cheaper by an average of €2.77 per patient (95% CI -€3.02 – €8.55), although this was statistically a non-significant finding. Sensitivity analyses indicate that the community service model may be significantly cheaper from the societal perspective. Semi-structured interviews with patients, community and hospital nurses involved in cancer care in the West of Ireland were analysed using thematic analysis. Four themes of improved patient experience, nurse-patient relationship, the importance of location and roadblocks to further implementation of the programme emerged. All interviewees expressed their belief that the introduction of the programme was a positive for patients. The cost and qualitative impact of the monitoring of OATs was assessed. The median consultation time was 33 minutes, costing an average of €22.10 per consultation, using Clinical Nurse Specialist salary figures and €26.51 per consultation, using Advanced Nurse Practitioner salary figures. The associated patient cost was €14.06 using the Human Capital method to calculate costs incurred from lost work productivity. Themes of the effect of Covid-19 on the service, expanding and complicated care package requirements, the need for dedicated oral clinics and the future of the service emerged from the interview data. Care of the older person in Ireland also equates to a significant cost to the Irish Healthcare system. A clinical decision support system, used to apply the STOPP/START version 2 criteria to older persons in hospital across Europe, was assessed for cost-effectiveness. The data within this thesis analysed the cost-effectiveness and costs of the Irish data using simple difference and Seemingly Unrelated REGression (SUREG) models. The intervention showed no significant improvement in quality of life. By simple difference, the average difference in total costs was €757 per participant in favour of the intervention group, this was not a significant finding (p=0.790). In the SUREG model the intervention showed a cost saving of €1477 per participant, not a significant difference. (p=0.341). Conclusion: The novel findings of this thesis offer insight into the effectiveness of the services and the potential for alternative methods of care delivery to be incorporated into national policy. The Irish healthcare system is in the midst of a reformation as part of the Sláintecare strategy, and the findings of this thesis are supportive of its drive towards a shift to primary care. The findings of this thesis provide specific information for policy makers on the examined interventions, and provides a roadmap for future research of novel evaluations targeting the vulnerable population groups assessed here.
Cancer , Older persons , Health economics , Qualitative
O'Mahony, C. D. 2021. A mixed-methods evaluation of novel services for vulnerable patient groups in Ireland. PhD Thesis, University College Cork.
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