Economic evaluations of assisted reproductive technologies in high-income countries: a systematic review

STUDY QUESTION

Which assited reproductive technology (ART) interventions in high-income countries are cost-effective and which are not?

SUMMARY ANSWER

Among all ART interventions assessed in economic evaluations, most high-cost interventions, including preimplantation genetic testing for aneuploidy (PGT-A) for a general population and ICSI for unexplained infertility, are unlikely to be cost-effective owing to minimal or no increase in effectiveness.

WHAT IS KNOWN ALREADY

Approaches to reduce costs in order to increase access have been identified as a research priority for future infertility research. There has been an increasing number of ART interventions implemented in routine clinical practice globally, before robust assessments of evidence on economic evaluations. The extent of clinical effectiveness of some studied comparisons has been evaluated in high-quality research, allowing more informative decision making around cost-effectiveness.

STUDY DESIGN, SIZE, DURATION

We performed a systematic review and searched seven databases (MEDLINE, PUBMED, EMBASE, COCHRANE, ECONLIT, SCOPUS, and CINAHL) for studies examining ART interventions for infertility together with an economic evaluation component (cost-effectiveness, cost-benefit, cost-utility, or cost-minimization assessment), in high-income countries, published since January 2011. The last search was 22 June 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two independent reviewers assessed publications and included those fulfilling the eligibility criteria. Studies were examined to assess the cost-effectiveness of the studied intervention, as well as the reporting quality of the study. The chosen outcome measure and payer perspective were also noted. Completeness of reporting was assessed against the Consolidated Health Economic Evaluation Reporting Standard. Results are presented and summarized based on the intervention studied.

MAIN RESULTS AND THE ROLE OF CHANCE

The review included 40 studies which were conducted in 11 high-income countries. Most studies (n = 34) included a cost-effectiveness analysis. ART interventions included medication or strategies for controlled ovarian stimulation (n = 15), IVF (n = 9), PGT-A (n = 7), single embryo transfer (n = 5), ICSI (n = 3), and freeze-all embryo transfer (n = 1). Live birth was the mostly commonly reported primary outcome (n = 27), and quality-adjusted life years was reported in three studies. The health funder perspective was used in 85% (n = 34) of studies. None of the included studies measured patient preference for treatment. It remains uncertain whether PGT-A improves pregnancy rates compared to IVF cycles managed without PGT-A, and therefore cost-effectiveness could not be demonstrated for this intervention. Similarly, ICSI in non-male factor infertility appears not to be clinically effective compared to standard fertilization in an IVF cycle and is therefore not cost-effective. Interventions such as use of biosimilars or HMG for ovarian stimulation are cheaper but compromise clinical effectiveness.

LIMITATIONS, REASONS FOR CAUTION

Lack of both preference-based and standardized outcomes limits the comparability of results across studies. The selection of efficacy evidence offered for some interventions for economic evaluations is not always based on high-quality randomized trials and systematic reviews. In addition, there is insufficient knowledge of the willingness to pay thresholds of individuals and state funders for treatment of infertility. There is variable quality of reporting scores, which might increase uncertainty around the cost-effectiveness results.

WIDER IMPLICATIONS OF THE FINDINGS

Investment in strategies to help infertile people who utilize ART is justifiable at both personal and population levels. This systematic review may assist ART funders decide how to best invest to maximize the likelihood of delivery of a healthy child.

STUDY FUNDING/COMPETING INTEREST(S)

There was no funding for this study. E.C. and R.W. receive salary support from the National Health and Medical Research Council (NHMRC) through their fellowship scheme (EC GNT1159536, RW 2021/GNT2009767). M.D.-T. reports consulting fees from King Fahad Medical School. All other authors have no competing interests to declare.

REGISTRATION NUMBER

Prospero CRD42021261537.

Leadership conceptions of nurses and physicians in emergency care: A scoping review

BACKGROUND

The Emergency Department (ED) is a setting where teamwork and leadership is imperative, however, the literature to date is mostly discipline (nursing or medical) specific. This scoping review aimed to map what is known about nurses' and physicians' conceptions of leadership in the ED to understand similarities, differences, and opportunities for leadership development and research.

METHOD

Guided by the Joanna Briggs Institute approach, and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Guidelines, a systematic search of three electronic databases was performed. The Mixed Methods Assessment Tool was used for quality appraisal of included articles.

RESULTS

In total, 37 articles were included. Four key findings emerged: 1) leadership was rarely explicitly defined; 2) nurse leaders tended to be characterised as agents of continuity whilst physician leaders tended to be characterised as agents of change and continuity; 3) the clarification of expectations from nurse leaders was more evident than expectations from physician leaders; and 4) leadership discourse tended to be traditional rather than contemporary.

CONCLUSION

Despite the proliferation of studies into ED nurse, physician and interprofessional leadership, opportunities exist to integrate learnings from other sectors to strengthen the development of current and next generation of ED leaders.

Associations between child maltreatment and hospital admissions for alcohol and other substance use-related disorders up to 40 years of age: Results from the Childhood Adversity and Lifetime Morbidity study

BACKGROUND AND AIMS

Evidence on the associations between child maltreatment (CM), alcohol use disorders (AUDs) and other substance use disorders (SUDs) comes largely from retrospective studies. These rely on self-reported data, which may be impacted by recall bias. Using prospective CM reports to statutory agencies, we measured associations between CM notifications and inpatient admissions for AUDs and SUDs up to 40 years of age.

DESIGN, SETTING AND PARTICIPANTS

Observational study linking administrative health data from Queensland, Australia to prospective birth cohort data comprising both agency-reported and substantiated notifications of CM.

MEASUREMENTS

Outcomes were inpatient admissions for AUDs and SUDs based on ICD-10-Australian modification (AM)-coded primary diagnoses. Unadjusted and adjusted logistic regression analyses were undertaken.

FINDINGS

Ten per cent (n = 609) of the cohort had a history of agency-reported or substantiated CM notifications before age 15. These individuals had higher adjusted odds of being admitted for AUDs and SUDs. For AUDs, the adjusted odds of inpatient admission were 2.86 [95% confidence interval (CI) = 1.73-4.74] greater where there was any previous agency-reported CM and 3.38 (95% CI = 1.94-5.89) greater where there was any previous substantiated CM. For SUDs, the adjusted odds of inpatient admission were 3.34 (95% CI = 2.42-4.61) greater where there was any previous agency-reported CM and 2.98 (95% CI = 2.04-4.36) greater where there was any previous substantiated CM.

CONCLUSIONS

People with a history of child maltreatment appear to have significantly higher odds of inpatient admissions for alcohol use disorders and other substance use disorders up to 40 years of age compared to people with no history of child maltreatment.

Emergency department presentations for deliberate self-harm and suicidal ideation in 25-39 years olds following agency-notified child maltreatment: results from the Childhood Adversity and Lifetime Morbidity (CALM) study

AIMS

To compare prospective reports of child maltreatment (CM) with emergency department (ED) presentations for deliberate self-harm (DSH) and suicidal ideation in individuals aged between 25 and 39 years old.

METHODS

Linked records between the Mater-University of Queensland Study of Pregnancy birth cohort and Queensland administrative health data were used, which included notifications to child protection agencies for CM. ED presentations for individuals aged between 25 and 39 years of age for suicidal ideation, suicidal behaviour or poisoning by paracetamol or psychotropic medications where the intention was unclear were examined using logistic regression analyses.

RESULTS

A total of 609 (10.1%) individuals were the subject of one or more CM notifications for neglect or physical, sexual or emotional abuse before the age of 15 years. Of these, 250 (4.1%) presented at least once to ED for DSH and/or suicidal ideation between 25 and 39 years of age. In adjusted analysis, any notification of CM was associated with significantly increased odds of presenting to ED for these reasons (aOR = 2.80; 95% CI = 2.04-3.84). In sensitivity analyses, any notification of CM increased the odds of the combined outcome of DSH and suicidal ideation by 275% (aOR = 2.75; 95% CI = 1.96-4.06) and increased the odds of DSH alone by 269% (aOR = 2.69; 95% CI = 1.65-4.41).

CONCLUSIONS

All CM types (including emotional abuse and neglect) were associated with ED presentations for DSH and suicidal ideation in individuals between 25 and 39 years of age. These findings have important implications for the prevention of DSH, suicidal ideation and other health outcomes. They also underscore the importance of trauma-informed care in ED for all individuals presenting with DSH and suicidal ideation.

Patterns in the provision of government-subsidised hormonal postpartum contraception in Queensland, Australia between 2012 and 2018: a population-based cohort study

BACKGROUND

Short birth intervals and unintended pregnancy are associated with poorer maternal and infant outcomes. There is a risk of pregnancy during the immediate postpartum period unless contraception is initiated. This retrospective cohort study aimed to capture the current patterns of hormonal contraceptive provision within 12 months postpartum in a high-income country.

METHODS

We used a linked administrative dataset comprising all women who gave birth in Queensland, Australia between 1 July 2012 and 30 June 2018 (n=339 265 pregnancies). We described our cohort by whether they were provided with government-subsidised hormonal contraception within 12 months postpartum. The associations between hormonal postpartum contraceptive provision and demographic and clinical characteristics were examined using univariate and multivariate logistic regression and presented in terms of crude and adjusted odds ratios with 95% confidence intervals.

RESULTS

A majority of women (60.2%) were not provided with government-subsidised hormonal postpartum contraception within 12 months postpartum. Women who were younger (<25 years), were overweight or obese, smoked, were born in Australia, were non-Indigenous, gave birth in a public hospital, or were in the lowest socioeconomic status group were more likely to be provided with postpartum contraception after adjusting for other covariates, compared with their counterparts.

CONCLUSIONS

Strategies to increase the provision and uptake of contraception in the immediate postpartum period are needed to prevent short birth intervals and unintended pregnancy and ensure women's fertility intentions are enacted. Ongoing research is needed to examine the factors influencing women's access to contraceptive services and, further, the types of contraception provided.

Development, women-centricity and psychometric properties of maternity patient-reported outcome measures (PROMs): A systematic review

BACKGROUND

Measuring maternity care outcomes based on what women value is critical to promoting woman-centred maternity care. Patient-reported outcome measures (PROMs) are instruments that enable service users to assess healthcare service and system performance.

AIM

To identify and critically appraise the risk of bias, woman-centricity (content validity) and psychometric properties of maternity PROMs published in the scientific literature.

METHODS

MEDLINE, CINAHL Plus, PsycINFO and Embase were systematically searched for relevant records between 01/01/2010 and 07/10/2021. Included articles underwent risk of bias, content validity and psychometric properties assessments in line with COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidance. PROM results were summarised according to language subgroups and an overall recommendation for use was determined.

FINDINGS

Forty-four studies reported on the development and psychometric evaluation of 9 maternity PROMs, grouped into 32 language subgroups. Risk of bias assessments for the PROM development and content validity showed inadequate or doubtful methodological quality. Internal consistency reliability, hypothesis testing (for construct validity), structural validity and test-retest reliability varied markedly in sufficiency and evidence quality. No PROMs received a level 'A' recommendation, required for real-world use.

CONCLUSION

Maternity PROMs identified in this systematic review had poor quality evidence for their measurement properties and lacked sufficient content validity, indicating a lack of woman-centricity in instrument development. Future research should prioritise women's voices in deciding what is relevant, comprehensive and comprehensible to measure, as this will impact overall validity and reliability and facilitate real-world use.

Development, woman-centricity and psychometric properties of maternity patient-reported experience measures: a systematic review

OBJECTIVE

Valid and reliable maternity patient-reported experience measures are critical to understanding women's experiences of care. They can support clinical practice, health service and system performance measurement, and research. The aim of this review is to identify and critically appraise the risk of bias, woman-centricity (content validity), and psychometric properties of maternity patient-reported experience measures published in the scientific literature.

DATA SOURCES

MEDLINE, CINAHL Plus, PsycINFO, and Embase were systematically searched for relevant records between January 1, 2010 and July 10, 2021.

STUDY ELIGIBILITY CRITERIA

We searched for articles describing the instrument development of maternity patient-reported experience measures and measurement properties associated with instrument validity and reliability testing. Articles that described patient-reported experience measures developed outside of the maternity context and articles that did not contribute to the instruments' development, content validation, and/or psychometric evaluation were excluded.

METHODS

Included articles underwent risk of bias, content validity, and psychometric properties assessments in line with the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) guidance. Patient-reported experience measure results were summarized according to language subgroups. An overall recommendation for use was determined for each patient-reported experience measure language subgroup.

RESULTS

A total of 54 studies reported on the development and psychometric evaluation of 25 maternity patient-reported experience measures, grouped into 45 language subgroups. The quality of evidence underpinning the instruments' development was generally poor. Only 2 (4.4%) patient-reported experience measures reported sufficient content validity, and only 1 (2.2%) received a level "A" recommendation, required for real-world use.

CONCLUSION

Maternity patient-reported experience measures demonstrated poor-quality evidence for their measurement properties and insufficient detail about content validity. Future maternity patient-reported experience measure development needs to prioritize women's involvement in deciding what is relevant, comprehensive, and comprehensible to measure. Improving the content validity of maternity patient-reported experience measures will improve overall validity and reliability and facilitate real-world practice improvements. Standardized patient-reported experience measure implementation also needs to be prioritized to support advancements in clinical practice for women.

Health Economics and Equity in Preconception Health Care: A Systematic Review

Poor pregnancy outcomes affect a child's lifelong health and disadvantaged populations are at higher risk of poor pregnancy outcomes. Preconception care aims to improve pregnancy outcomes by managing conditions and risks prior to conception. Given known inequities in pregnancy outcomes, the adoption of preconception care may benefit disadvantaged populations. Health economics plays an important role in the implementation of interventions, as economic evaluations seek to identify the most efficient and equitable care options. This review aimed to identify the cost-effectiveness of preconception care and how equity has been considered in these evaluations. A systematic review of literature published between 2012-2022 was undertaken to identify studies that evaluate the economic outcomes of preconception care. Studies that met the inclusion criteria were manually searched for consideration of equity in the economic evaluation analysis. Costs were presented and a narrative synthesis of studies reporting on outcomes of equity was conducted. Eight studies met the inclusion criteria, and only two reported on aspects of equity, specifically ethnicity. Considering the significant disparities in pregnancy outcomes among disadvantaged populations, aspects of equity are important to consider when implementing and evaluating preconception interventions. Therefore, it is recommended that future research focuses on the cost-effectiveness of preconception care and that these evaluations incorporate aspects of equity.

'I knew I'd be taken care of': Exploring patient experiences in the Emergency Department

Aims

To explore adult Emergency Department patient experiences to inform the development of a new Emergency Department patient‐reported experience measure.

Design

Descriptive, exploratory qualitative study using semi‐structured individual interviews with adult Emergency Department patients.

Methodology

Participants were recruited across two Emergency Departments in Southeast Queensland, Australia during September and October 2020. Purposive sampling based on maximum variation was used. Participants were recruited during their Emergency Department presentation and interviewed in 2‐weeks via telephone. Inductive thematic analysis followed the approach proposed by Braun and Clarke (2012).

Results

Thirty participants were interviewed, and four themes were inductively identified: Caring relationships between patients and Emergency Department care providers; Being in the Emergency Department environment; Variations in waiting for care; and Having a companion in the Emergency Department. Caring relationships between patients and Emergency Department care providers included being treated like a person and being cared for, being informed about and included in care, and feeling confident in care providers. Being in the Emergency Department environment included being around other patients, feeling comfortable and having privacy. Variations in waiting for care included expecting a longer wait, waiting throughout the Emergency Department journey and receiving timely care. Having a companion in the Emergency Department included not feeling alone, and observing care providers engage with companions.

Conclusion

Patient experiences in the Emergency Department are multifaceted, and themes are not mutually exclusive. These findings demonstrate consistency with the core experiential themes identified in the international literature.

Impact

Strategies to improve patient engagement in shared decision‐making, and communication between patients and care providers about wait times will be critical to optimizing Emergency Department patient experiences, and person‐centred practice. These findings holistically conceptualize patient experiences in the Emergency Department which is the first step to developing a new Emergency Department patient‐reported experience measure.

Income support for parents of children with chronic conditions and disability: where do we draw the line? A policy review

OBJECTIVE

The aim of this review was to identify and describe whether parents who have had to stop paid employment to care for a child with a chronic condition or disability are eligible for unemployment, family and children, and disability and carer government-provided financial benefits.

DESIGN

Policy review.

SETTING

Group of seven high-income countries.

MAIN OUTCOME MEASURES

All policies related to unemployment, family and children, and disability and carer benefits were included. Information regarding the policy type and description, parent/carer qualification, amount of financial support payable, eligibility criteria and information source were extracted. Payment schedules were converted into 2020 US dollars, using Purchasing Power Parities. Maximum monthly benefit payments were compared with standardised per capita monthly costs of living to determine payment support suitability.

RESULTS

Fifty-eight policies relevant to unemployment, family and children, and disability and carer benefit supports were identified. Germany had the highest number of welfare policies for individuals not in employment (n=11), followed by the USA (n=6). Parents or carers of children with chronic conditions or disability who were not in employment qualified for 31 of the 58 policies (53.4%). Most policies required a child to have an impaired ability to function, not just a chronic condition or disability.

CONCLUSIONS

Greater support for parents and carers to continue their paid employment alongside caring responsibilities is necessary. Graded benefit schedules will also be critical to supporting the spectrum of childhood chronic conditions and disability, and the subsequent spectrum of caring responsibility.

Establishing the content validity of a new emergency department patient-reported experience measure (ED PREM): a Delphi study

Background

Patient-reported experience measures aim to capture the patient’s perspective of what happened during a care encounter and how it happened. However, due to a lack of guidance to support patient-reported experience measure development and reporting, the content validity of many instruments is unclear and ambiguous. Thus, the aim of this study was to establish the content validity of a newly developed Emergency Department Patient-Reported Experience Measure (ED PREM).

Methods

ED PREM items were developed based on the findings of a systematic mixed studies review, and qualitative interviews with Emergency Department patients that occurred during September and October, 2020. Individuals who participated in the qualitative interviews were approached again during August 2021 to participate in the ED PREM content validation study. The preliminary ED PREM comprised 37 items. A two-round modified, online Delphi study was undertaken where patient participants were asked to rate the clarity, relevance, and importance of ED PREM items on a 4-point content validity index scale. Each round lasted for two-weeks, with 1 week in between for analysis. Consensus was a priori defined as item-level content validity index scores of ≥0.80. A scale-level content validity index score was also calculated.

Results

Fifteen patients participated in both rounds of the online Delphi study. At the completion of the study, two items were dropped and 13 were revised, resulting in a 35-item ED PREM. The scale-level content validity index score for the final 35-item instrument was 0.95.

Conclusions

The newly developed ED PREM demonstrates good content validity and aligns strongly with the concept of Emergency Department patient experience as described in the literature. The ED PREM will next be administered in a larger study to establish its’ construct validity and reliability. There is an imperative for clear guidance on PREM content validation methodologies. Thus, this study may inform the efforts of other researchers undertaking PREM content validation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00617-5.

Inequities in vulnerable children’s access to health services in Australia

Introduction

Children born into families at risk of becoming or remaining poor are at significant risk of experiencing childhood poverty, which can impair their start to life, and perpetuate intergenerational cycles of poverty. This study sought to quantify health service utilisation, costs and funding distribution amongst children born into vulnerable compared to non-vulnerable families.

Methods

This study used a large linked administrative dataset for all women giving birth in Queensland, Australia between July 2012 and July 2018. Health service use included inpatient, emergency department (ED), general practice, specialist, pathology and diagnostic imaging services. Costs included those paid by public hospital funders, private health insurers, Medicare and out-of-pocket costs.

Results

Vulnerable children comprised 34.1% of the study cohort. Compared with non-vulnerable children, they used significantly higher average numbers of ED services during the first 5 years of life (2.52±3.63 vs 1.97±2.77), and significantly lower average numbers of specialist, pathology and diagnostic imaging services. Vulnerable children incurred significantly greater costs to public hospital funders compared with non-vulnerable children over the first 5 years of life ($16 053 vs $10 247), and significantly lower private health insurer, Medicare and out-of-pocket costs.

Conclusion

There are clear inequities in vulnerable children’s health service utilisation in Australia. Greater examination of the uptake and cost-effectiveness of maternal and child services is needed, as these services support children’s development in the critical first 1000 days of life.

Evaluating the development, woman-centricity and psychometric properties of maternity patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs): A systematic review protocol

INTRODUCTION

Woman-centred care is the right of every woman receiving maternity care, irrespective of where care is being received and who is providing care. This protocol describes a planned systematic review that will identify, describe and critically appraise the psychometric properties of maternity patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs). The woman-centricity of PROM and PREM development and content validation (ie, the extent to which women were involved in these processes) will also be assessed. This information will be used to develop a maternity PROMs and PREMs database to support service and system performance measurement, and value-based maternity care initiatives.

METHODS AND ANALYSIS

This study will be guided by the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline for systematic reviews of outcome measurement instruments. Studies identified via MEDLINE, CINAHL Plus, PsycINFO and EMBASE describing the development, content validation and/or psychometric evaluation of PROMs and PREMs specifically designed for maternity populations throughout pregnancy, childbirth and postnatal periods will be considered if published from 2010 onward, in English, and available in full text. The COSMIN risk of bias checklist will be used to evaluate the quality of studies reporting on the development, content validation and/or psychometric evaluation of PROMs and PREMs. COSMIN criteria for good content validity will be used to assess the woman-centricity of PROM and PREM development and content validation studies. COSMIN standards of good psychometric properties will be used to evaluate the validity and reliability of the identified instruments.

ETHICS AND DISSEMINATION

Ethical permission for this research is not required. The findings of this research will be submitted for publication in an international, peer-reviewed journal. Abstracts for national and international conference presentations will also be submitted. The proposed maternity PROMs and PREMs database will be freely accessible online, and developed with consumer input to ensure its usefulness to a range of maternity care stakeholders.

PROSPERO REGISTRATION NUMBER

CRD42021288854.

Inequality in early childhood chronic health conditions requiring hospitalisation: A data linkage study of health service utilisation and costs

BACKGROUND

The cost of socioeconomic inequality in health service use among Australian children with chronic health conditions is poorly understood.

OBJECTIVES

To quantify the cost of socioeconomic inequality in health service use among Australian children with chronic health conditions.

METHODS

Cohort study using a whole-of-population linked administrative data for all births in Queensland, Australia, between July 2015 and July 2018. Socioeconomic status was defined by an areas-based measure, grouping children into quintiles from most disadvantaged (Q1) to least disadvantaged (Q5) based on their postcode at birth. Study outcomes included health service utilisation (inpatient, emergency department, outpatient, general practitioner, specialist, pathology and diagnostic imaging services) and healthcare costs.

RESULTS

Of the 238,600 children included in the analysis, 10.4% had at least one chronic health condition. Children with chronic health conditions in Q1 had higher rates of inpatient (6.6, 95% confidence interval [CI] 6.4, 6.7), emergency department (7.2, 95% CI 7.0, 7.5) and outpatient (20.3, 95% CI 19.4, 21.3) service use compared to children with chronic health conditions in Q5. They also had lower rates of general practitioner (37.5, 95% CI 36.7, 38.4), specialist (8.9, 95% CI 8.5, 9.3), pathology (10.7, 95% CI 10.2, 11.3), and diagnostic imaging (4.3, 95% CI 4.2,4.5) service use. Children with any chronic health condition in Q1 incurred lower median out-of-pocket fees than children in Q5 ($0 vs $741, respectively), lower median Medicare funding ($2710, vs $3408, respectively), and higher median public hospital funding ($31, 052 vs $23, 017, respectively).

CONCLUSIONS

Children of most disadvantage are more likely to access public hospital provided services, which are accessible free of charge to patients. These children are less likely to access general practitioner, specialist, pathology and diagnostic imaging services; all of which are critical to the ongoing management of chronic health conditions, but often attract an out-of-pocket fee.

Using epidemiological and health economic measures to inform maternity staffing decisions: A guide

BACKGROUND

There is growing concern around unnecessary intervention (particularly caesarean section) at birth in high-income countries. Caseload midwifery care aims to offset this, but is perceived to be costly to health services.

AIM

To use epidemiological and health economic techniques to estimate health outcomes and cost-savings of different levels of equivalent full time (EFT) midwives working in caseload midwifery care.

METHODS

Two simulations were conducted - one assuming 10 EFT midwives working in a caseload model, with 35 women per caseload, and one assuming 50 EFT midwives working in a caseload model, with 45 women per caseload. Both were based on a sample of 5000 women. The main model inputs included rates of health outcomes for women (caesarean section, epidural anaesthesia, and episiotomy) and infants (low birthweight and admissions to special care nursery (SCN) or neonatal intensive care unit (NICU)), and the cost savings associated with health outcome avoidance.

FINDINGS

The first simulation estimated 27 fewer caesarean sections, 12 fewer epidurals, 12 fewer episiotomies, 10 fewer low birthweight births, and 23 fewer infants admitted to SCN or NICU annually, at a total cost saving of AU$1,874,715. The second simulation estimated 173 fewer caesarean sections, 76 fewer epidurals, 76 fewer episiotomies, 65 fewer low birthweight births, and 150 fewer infants admitted to SCN or NICU annually, at a total cost saving of AU$12,051,741.

CONCLUSION

This study provides local-level decision-makers with a decision-tool to calculate the potentially avoidable health outcomes and cost savings associated with implementing caseload midwifery care in their own service.

Quantifying the differences in birth outcomes and out-of-pocket costs between Australian Defence Force servicewomen and civilian women: A data linkage study

OBJECTIVES

Servicewomen in Defence Forces the world over are constrained in their health service use by defence healthcare policy. These policies govern a woman's ability to choose who she receives maternity care from and where. The aim of this study was to compare Australian Defence Force (ADF) servicewomen and children's birth outcomes, health service use, and out-of-pocket costs to those of civilian women and children.

METHODS

Retrospective cohort study using linked administrative data for women giving birth between 1 July 2012 and 30 June 2018 in Queensland, Australia (n = 365,138 births). Women serving in the ADF at the time of birth were identified as having their care funded by the Department of Defence (n = 395 births). Propensity score matching was used to identify a mixed public/private civilian sample of women to allow for comparison with servicewomen, controlling for baseline characteristics. Sensitivity analysis was also conducted using a sample of civilian women accessing only private maternity care.

FINDINGS

Nearly all servicewomen gave birth in the private setting (97.22%). They had significantly greater odds of having a caesarean section (OR 1.71, 95%CI 1.29-2.30) and epidural (OR 1.56, 95%CI 1.11-2.20), and significantly lower odds of having a non-instrumental vaginal birth (OR 0.57, 95%CI 0.43-0.75) compared to women in the matched public/private civilian sample. Compared to civilian children, children born to servicewomen had significantly higher out-of-pocket costs at birth ($275.93 ± 355.82), in the first ($214.98 ± 403.45) and second ($127.75 ± 391.13) years of life, and overall up to two years of age ($618.66 ± 779.67) despite similar health service use.

CONCLUSIONS

ADF servicewomen have higher rates of obstetric intervention at birth and also pay significantly higher out-of-pocket costs for their children's health service utilisation up to 2-years of age. Given the high rates of obstetric intervention, greater exploration of servicewomen's maternity care experiences and preferences is warranted, as this may necessitate further reform to ADF maternity healthcare policy.

Cost of intimate partner violence during pregnancy and postpartum to health services: a data linkage study in Queensland, Australia

To quantify health service costs of intimate partner violence (IPV) during pregnancy and postpartum; and to compare health service costs between women who reported IPV, versus women who did not report IPV. This was a cohort study using linked data for a publicly funded Australian tertiary hospital maternity service. Participants included all women accessing antenatal services between August 2016 and August 2018. Routinely collected IPV data were linked to women's admitted, non-admitted, emergency department, perinatal, and costing data from 6 months prior to reporting IPV through to 12 months post-birth. Of the 9889 women receiving maternity care, 280 (2.9%) reported some form of IPV with 72 (24.8%) referred to support. Women who reported IPV generated higher mean total costs than women not reporting IPV ($12,772 vs $10,166, respectively). Between-group differences were significant after adjusting for demographic and clinical factors (cost ratio 1.24, 95% CI: 1.15-1.34). There were no significant differences in mean total costs for babies where IPV was and was not reported ($4971 vs $5340, respectively). IPV is costly for health services. However, greater research is needed to comprehensively estimate the long-term health service costs associated with IPV. Furthermore, the limitations associated with routinely collected IPV data suggest that standardised screening practices and innovative data linkage and modelling approaches are required to collect data that truly represents the burden and costs associated with IPV.

The opportunity costs of birth in Australia: Hospital resource savings for a post-COVID-19 era

BACKGROUND

COVID-19 caused significant disruptions to health systems globally; however, restricting the family presence during birth saw an increase in women considering community birth options. This study aimed to quantify the hospital resource savings that could occur if all low-risk women in Australia gave birth at home or in birth centers.

METHODS

A whole-of-population linked administrative data set containing all women (n = 44 498) who gave birth in Queensland, Australia, between 01/07/2012 and 30/06/2015 was reweighted to represent all Australian women giving birth in 2017. A static microsimulation model of woman and infant health service resource use was created based on 2017 data. The model was comprised of a base model, representing "current" care, and a counterfactual model, representing hypothetical scenarios where all low-risk Australian women gave birth at home or in birth centers.

RESULTS

If all low-risk women gave birth at home in 2017, cesarean rates would have reduced from 13.4% to 2.7%. Similarly, there would have been 860 fewer inpatient bed days and 10.1 fewer hours of women's intensive care unit time per 1000 births. If all women gave birth in birth centers, cesarean rates would have reduced to 6.7%. In addition, over 760 inpatient bed days would have been saved along with 5.6 hours of women's intensive care unit time per 1000 births.

CONCLUSIONS

Significant health resource savings could occur by shifting low-risk births from hospitals to home birth and birth center services. Greater examination of Australian women's preferences for home birth and birth center birth models of care is needed.

A systematic mixed studies review of patient experiences in the ED

BACKGROUND

Understanding patient experiences is crucial to evaluating care quality in EDs. However, while previous reviews describe the determinants of ED patient experiences (ie, factors that influence patient experiences), few have described actual patient experiences. The aim of this systematic mixed studies review was to describe patient experiences in the ED from the patient's perspective.

METHODS

Embase, Medline, ProQuest Nursing and Allied Health, the Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library electronic databases were searched, with publication dates limited between 1 January 2001 and 16 September 2019. Studies describing adult patient experiences in the ED were included. Studies describing patient satisfaction, proxy-reported experiences or child/adolescent experiences were excluded. The quality of included studies was appraised using the Mixed Methods Appraisal Tool (2018 version). An inductive, convergent qualitative synthesis of the extracted data was undertaken following Thomas and Harden's (2008) methods.

RESULTS

Fifty-four studies were included and of those, only five (9%) studies included a standardised definition of patient experience. Two inter-related themes emerged: Relationships between ED patients and care providers; and Spending time in the ED environment. The first theme included four subthemes regarding respect, communication, caring behaviours and optimising patient confidence. A key finding related to the potential for power imbalances between patients and their care providers. The second theme included two subthemes regarding physical aspects of the ED environment and patients' waiting experience. Patients attributed more importance to the waiting experience itself rather than the duration they had to wait.

CONCLUSIONS

Patients in the ED have unique and complex experiences. Greater research is needed to understand the relational and environmental factors that contribute to power imbalances between patients and care providers, how to support more positive waiting experiences, and developing a standardised definition of patient experience in the ED.

PROSPERO REGISTRATION NUMBER

CRD42020150154.

Does facility type and location impact upon patient experiences in emergency departments? Secondary analysis of a state-wide, cross-sectional survey

OBJECTIVE

To identify the extent to which patient experiences in the ED differ depending on facility type (based on bed numbers, services available and annual separations), and location (level of remoteness).

METHODS

Data from a 2015 state-wide (Queensland, Australia) public ED patient experience survey were linked to sociodemographic and presentation-related characteristics data. Survey items were individually scored (from 0 to 100), and averaged across 13 pre-determined patient experience topic areas. Descriptive statistics were used to report on patient sociodemographic and presentation-related characteristics. One-way analysis of variance tests were used to identify associations between patient-reported experience scores, facility types and location.

RESULTS

A total of 10 553 patients over the age of 16 years completed the survey. All patients reported scores above 75 for 7 of the 13 patient experience topic areas (0 = lowest score, 100 = highest score). Patients from very remote and outer regional EDs reported the highest scores for the topic Environment and facilities, and remote facility patients reported the highest scores for the topic Leaving the ED - Delays. The same two topic areas were scored most highly by patients from smaller facilities in comparison to principal referral hospital EDs.

CONCLUSIONS

Patients attending smaller and more rurally located EDs reported more positive experiences than those attending larger, metropolitan EDs on two of the 13 topic areas. However, these differences were marginal. Future research should aim to determine what constitutes clinically meaningful differences between groups when comparing patient-reported experience scores, and understand the characteristics of small and rural EDs that may be associated with better patient experiences.

The Dietary Patterns of Japanese Hemodialysis Patients: A Focused Ethnography

The relationship between diet and kidney disease outcomes has been established, and as a result, hemodialysis patients are required to modify their diet. However, there is a gap in understanding how diet is influenced by social factors, particularly among Japanese patients whose diet is known to be high in salt. The purpose was to explore the dietary patterns of Japanese hemodialysis patients and better understand the challenges they face in adhering to dietary restrictions. A focused ethnography, employing observational methods with six Japanese hemodialysis patients was undertaken. Fieldwork included observations, informal interviews, and weekly formal interviews for 6 weeks. Five categories were identified during the process of data analysis. This study highlights the strong influence of culture, tradition, and family on the dietary patterns of Japanese hemodialysis patients, which has rarely been acknowledged by Japanese health professionals. The translated abstract was prepared by the author based on the accepted English version of the original abstract. Only light additional review of the translation has been completed by the journal.

A systematic review of the validity and reliability of patient-reported experience measures

OBJECTIVES

To identify patient-reported experience measures (PREMs), assess their validity and reliability, and assess any bias in the study design of PREM validity and reliability testing.

DATA SOURCES/STUDY SETTING

Articles reporting on PREM development and testing sourced from MEDLINE, CINAHL and Scopus databases up to March 13, 2018.

STUDY DESIGN

Systematic review.

DATA COLLECTION/EXTRACTION METHODS

Critical appraisal of PREM study design was undertaken using the Appraisal tool for Cross-Sectional Studies (AXIS). Critical appraisal of PREM validity and reliability was undertaken using a revised version of the COSMIN checklist.

PRINCIPAL FINDINGS

Eighty-eight PREMs were identified, spanning across four main health care contexts. PREM validity and reliability was supported by appropriate study designs. Internal consistency (n = 58, 65.2 percent), structural validity (n = 49, 55.1 percent), and content validity (n = 34, 38.2 percent) were the most frequently reported validity and reliability tests.

CONCLUSIONS

Careful consideration should be given when selecting PREMs, particularly as seven of the 10 validity and reliability criteria were not undertaken in ≥50 percent of the PREMs. Testing PREM responsiveness should be prioritized for the application of PREMs where the end user is measuring change over time. Assessing measurement error/agreement of PREMs is important to understand the clinical relevancy of PREM scores used in a health care evaluation capacity.

Registered nurses' provision of end-of-life care to hospitalised adults: A mixed studies review

OBJECTIVES

To describe, critically appraise and synthesise research regarding nurses' perceptions of their knowledge, skills or experiences in providing end-of-life care to hospitalised adults to help inform both future educational and practice initiatives.

DESIGN

Mixed studies review.

DATA SOURCES

MEDLINE, CINAHL, Cochrane Library, Web of Science and SCOPUS databases were searched for the years 2004-June 2018, along with journal hand-searching and reference list searching.

REVIEW METHODS

Two independent reviewers screened the titles and abstracts of studies. Data extraction and quality assessment using the Mixed Methods Appraisal Tool was conducted independently by two reviewers. Disagreements were adjudicated by a third reviewer. Study findings were synthesised thematically.

RESULTS

Nineteen studies met the inclusion criteria. Of them, ten were quantitative, eight qualitative and one mixed-method. All but one quantitative study were conducted in the United States and all but one used some form of survey. The qualitative studies were conducted in a variety of countries and all but one used some form of interview for data collection. Five themes were identified including nurse as a protecting provider, nurse as an advocate, nurse as a reflective practitioner, obstacles to providing quality end-of-life care and aids to providing quality end-of-life care.

CONCLUSIONS

Registered Nurses have aligned their end-of-life care with practice with the profession's expectations and are enacting a patient centred approach to their practice. They rely on reflective practices and on the support of others to overcome organisational, educational and emotional the challenges they to providing quality end-of-life care.

Quality appraisal of clinical guidelines for surgical site infection prevention: A systematic review

Background

Surgical site infections (SSI) occur in up to 10% of surgeries. Wound care practices to prevent infections are guided by Clinical Practice Guidelines (CPGs), yet their contribution to improving patient outcomes relies on their quality and adoption in practice. We critically evaluated the quality of CPGs for SSI prevention during pre-, intra- and post-operative phases of care.

Methods

We systematically reviewed the literature from 1990–2018 using the Cochrane Library, CINAHL, EMBASE, MEDLINE, ProQuest databases and five guidelines repositories. We extracted characteristics of each guideline using purposely-developed data collection tools. We assessed overall quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

Results

Combined searches of databases and repositories yielded 5,910 citations. Of these, we reviewed 215 full text documents. The final sample included 15 documents: 6 complete CPGs, 3 CPG updates, and 6 supplementary documents. The overall %mean scores across AGREE II domains for CPGs were: 1) scope and purpose (%mean ± SD = 86.3±23.5); 2) stakeholder involvement (%mean ± SD = 64±31.0); 3) rigour of development (%mean ± SD = 68.7±30.6); 4) clarity and presentation (%mean ± SD = 88.5±16.7); 5) applicability (%mean ± SD = 44±30.2); and, 5) editorial independence (%mean ± SD = 61±37.6). Based on individual AGREE II domains and overall scores, we appraised 4 out of 6 CPGs (inclusive of updates) as “recommended” for use in practice. Overall agreement among appraisers was excellent (ICC 0.86 [95%CI 0.73–0.94] - 0.98 [95%CI 0.96–0.99]; p <0.001).

Discussion

International interest in CPG development has resulted in refinements to methodologies, which has led to improvements in the overall quality of the product.

Implications for translation

Given the domains that received the lowest scores, it is clear that we need more consumer involvement and better consideration of the implementation challenges with CPG uptake and sustainability.

Can you detect early dementia from an email? A proof of principle study of daily computer use to detect cognitive and functional decline

OBJECTIVE

To determine whether multiple computer use behaviours can distinguish between cognitively healthy older adults and those in the early stages of cognitive decline, and to investigate whether these behaviours are associated with cognitive and functional ability.

METHODS

Older adults with cognitive impairment (n = 20) and healthy controls (n = 24) completed assessments of cognitive and functional abilities and a series of semi-directed computer tasks. Computer use behaviours were captured passively using bespoke software.

RESULTS

The profile of computer use behaviours was significantly different in cognitively impaired compared with cognitively healthy control participants including more frequent pauses, slower typing, and a higher proportion of mouse clicks. These behaviours were significantly associated with performance on cognitive and functional assessments, in particular, those related to memory.

CONCLUSION

Unobtrusively capturing computer use behaviours offers the potential for early detection of neurodegeneration in non-clinical settings, which could enable timely interventions to ultimately improve long-term outcomes.

A novel role of the corticotrophin-releasing hormone regulating peptide, teneurin C-terminal associated peptide 1, on glucose uptake into the brain

Teneurin C-terminal associated peptide (TCAP) is an ancient paracrine signalling agent that evolved via lateral gene transfer from prokaryotes into an early metazoan ancestor. Although it bears structural similarity to corticotrophin-releasing hormone (CRH), it inhibits the in vivo actions of CRH. The TCAPs are highly expressed in neurones, where they induce rapid cytoskeletal rearrangement and are neuroprotective. Because these processes are highly energy-dependent, this suggests that TCAP has the potential to regulate glucose uptake because glucose is the primary energy substrate in brain, and neurones require a steady supply to meet the high metabolic demands of neuronal communication. Therefore, the objective of the present study was to assess the effect of TCAP-mediated glucose uptake in the brain and in neuronal cell models. TCAP-mediated ¹⁸ F-deoxyglucose (FDG) uptake into brain tissue was assessed in male wild-type Wistar rats by functional positron emission tomography. TCAP-1 increased FDG uptake by over 40% into cortical regions of the brain, demonstrating that TCAP-1 can significantly enhance glucose supply. Importantly, a single nanomolar injection of TCAP-1 increased brain glucose after 3 days and decreased blood glucose after 1 week. This is corroborated by a decreased serum concentration of insulin and an increased serum concentration of glucagon. In immortalised hypothalamic neurones, TCAP-1 increased ATP production and enhanced glucose uptake by increasing glucose transporter recruitment to the plasma membrane likely via AKT and mitogen-activated protein kinase/ERK phosphorylation events. Taken together, these data demonstrate that TCAP-1 increases glucose metabolism in neurones, and may represent a peptide signalling agent that regulated glucose uptake before insulin and related peptides.

Patient-centred care to improve dietetic practice: an integrative review

BACKGROUND

Patient-centred care (PCC) is associated with significant improvements in patients' health outcomes and healthcare systems. There is an opportunity to better understand PCC in dietetics. Thus, the present integrative review aims to critically synthesise literature relating to PCC in dietetics.

METHODS

A systematic literature search was conducted between February and March 2016. Studies were included if they (i) involved dietitians and/or patients who had participated in an individual dietetic consultation; (ii) related to one or more components of PCC; and (iii) were empirical full-text studies in English, involving adult participants, published between 1997 and 2016. Following title and abstract screening, full texts were retrieved and independently assessed for inclusion by two of the investigators. Two independent investigators conducted data extraction and quality assessment using the Mixed Methods Appraisal Tool. Study findings were analysed thematically using meta-synthesis. Twenty-seven studies met the inclusion criteria.

RESULTS

Six themes were discovered inductively: (i) establishing a positive dietitian-patient relationship; (ii) displaying humanistic behaviours; (iii) using effective communication skills; (iv) individualising and adapting care; (v) redistributing power to the patient; and (vi) lacking time for PCC practices. The first three themes were closely related. Studies used a broad range of methodological designs. Limitations of the studies included a lack of reflexivity and a lack of representativeness of the study population.

CONCLUSIONS

It is apparent that dietitians require good communication skills and humanistic qualities to build positive relationships with patients. Patients strongly desire individualised nutrition care and greater involvement in care. Ensuring dietitians are able to incorporate patient-centred practises during care requires further research.

Advancing pharmacovigilance through academic-legal collaboration: the case of gadolinium-based contrast agents and nephrogenic systemic fibrosis-a Research on Adverse Drug Events and Reports (RADAR) report

OBJECTIVE

To compare and contrast three databases, that is, The International Centre for Nephrogenic Systemic Fibrosis Registry (ICNSFR), the Food and Drug Administration Adverse Event Reporting System (FAERS) and a legal data set, through pharmacovigilance and to evaluate international nephrogenic systemic fibrosis (NSF) safety efforts.

METHODS

The Research on Adverse Drug events And Reports methodology was used for assessment-the FAERS (through June 2009), ICNSFR and the legal data set (January 2002 to December 2010). Safety information was obtained from the European Medicines Agency, the Danish Medicine Agency and the Food and Drug Administration.

RESULTS

The FAERS encompassed the largest number (n = 1395) of NSF reports. The ICNSFR contained the most complete (n = 335, 100%) histopathological data. A total of 382 individual biopsy-proven, product-specific NSF cases were analysed from the legal data set. 76.2% (291/382) identified exposure to gadodiamide, of which 67.7% (197/291) were unconfounded. Additionally, 40.1% (153/382) of cases involved gadopentetate dimeglumine, of which 48.4% (74/153) were unconfounded, while gadoversetamide was identified in 7.3% (28/382) of which 28.6% (8/28) were unconfounded. Some cases involved gadobenate dimeglumine or gadoteridol, 5.8% (22/382), all of which were confounded. The mean number of exposures to gadolinium-based contrast agents (GBCAs) was gadodiamide (3), gadopentetate dimeglumine (5) and gadoversetamide (2). Of the 279 unconfounded cases, all involved a linear-structured GBCA. 205 (73.5%) were a non-ionic GBCA while 74 (26.5%) were an ionic GBCA.

CONCLUSION

Clinical and legal databases exhibit unique characteristics that prove complementary in safety evaluations. Use of the legal data set allowed the identification of the most commonly implicated GBCA.

ADVANCES IN KNOWLEDGE

This article is the first to demonstrate explicitly the utility of a legal data set to pharmacovigilance research.

Gas hydrates at high pressure

The behaviour of gas hydrates at high pressure is of wide interest and importance. Gas hydrates are stablised by water-gas repulsive interactions. Information on the effect of changing density on these water-gas interactions provides fundamental insight into the nature of the water potential. Gas hydrates are also widely found in nature and systems like the ammonia-water and methane-water systems form the basis of 'mineralogy' of planetary bodies like Saturn's moon Titan. Finally, gas hydrates offer the possibility of cheap environmentally inert transportation and storage for gases like carbon dioxide and hydrogen. We have been carrying out investigations of a range of gas hydrates at high pressure using neutron and x-ray diffraction as well as other techniques. Results from these studies including; the phase diagram of the ammonia water system, the occupancies of hexgonal clathrate structures, and new structures in the carbon dioxide water system, will be presented.

Elevated plasma magnesium and calcium may be associated with shorter telomeres in older South Australian women

Telomeres are structures that cap the ends of chromosomes. The integrity of the telomere structure and its DNA hexamer (TTAGGG)n repeat sequence is critical for protecting the ends of chromosomes from degradation and in maintaining overall chromosomal stability. Currently, there are limited data on the influence that nutrition has on telomere length. Recent studies have suggested that micronutrients may influence telomere length. Here we examined the relationship between telomere length in lymphocytes and plasma calcium, magnesium, selenium and zinc status in a healthy cohort of younger and older adults. We report a negative association between telomere length and both plasma calcium and magnesium levels, (r=-0.47, P=0.03 and r=-0.61, P=0.001 respectively), in older females; Intriguingly Ca/Mg ratio was positively associated with telomere length (r=0.55, P=0.007). These relationships were not observed in the younger adults, nor in the older males. In conclusion, our study provides preliminary evidence suggesting that levels of plasma magnesium and calcium may impact on telomere length in lymphocytes in older women.