A mixed-methods evaluation of novel services for vulnerable patient groups in Ireland
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Date
2021-06
Authors
O'Mahony, Cian
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Publisher
University College Cork
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Abstract
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.
Description
Keywords
Cancer , Older persons , Health economics , Qualitative
Citation
O'Mahony, C. D. 2021. A mixed-methods evaluation of novel services for vulnerable patient groups in Ireland. PhD Thesis, University College Cork.