Serious violent offenders : developing a risk assessment framework

In order to establish a complementary language of risk across all agencies, it is recommended that the Scottish Government and the Risk Management Authority actively disseminate MAPPA guidance through the RMA's specialist training programme and through the development of protocols and memoranda of agreement. Prior to a violent offender framework being implemented, an audit of existing numbers, staffing, budgetary and other resources should be undertaken across the Community Justice Authorities to ascertain projected needs

Health systems and HIV treatment in sub-Saharan Africa: Matching intervention and program evaluation strategies

Objectives International donors financing the delivery of antiretroviral treatment (ART) in developing countries have recently emphasized their commitment to rigorous evaluation of ART impact on population health. In the same time frame but different contexts, they have announced that they will shift funding from vertically-structured (i.e., disease-specific) interventions to horizontally-structured interventions (i.e., staff, systems and infrastructure that can deliver care for many diseases). We analyze likely effects of the latter shift on the feasibility of impact evaluation. Methods We examine the effect of the shift in intervention strategy on (i) outcome measurement, (ii) cost measurement, (iii) study-design options, and the (iv) technical and (v) political feasibility of program evaluation. Results As intervention structure changes from vertical to horizontal, outcome and cost measurement are likely to become more difficult (because the number of relevant outcomes and costs increases and the sources holding data on these measures become more diverse); study design options become more limited (because it is often impossible to identify a rigorously defined counterfactual in horizontal interventions); the technical feasibility of interventions is reduced (because lag times between intervention and impact increase in length and effect mediating and modifying factors increase in number); and political feasibility of evaluation is decreased (because national policymakers may be reluctant to support the evaluation). Conclusions In the choice of intervention strategy, policymakers need to consider the effect of intervention strategy on impact evaluation. Methodological studies are needed to identify the best approaches to evaluate the population health impact of horizontal interventions.Impact evaluation, health systems, HIV, antiretroviral treatment, Africa

Development of the family doctor service: an evolutionary game theory analysis

Family physicians play a prominent role in the primary health care system of several countries and regions. This study examined family doctors, community residents, and general hospitals, and found that their behaviour and decisions were inevitably affected by multiple economic concerns. To explore the influence of these economic factors, we established a tripartite evolutionary game model. Based on this dynamic game model, we examined the equilibrium of their interactions, effects of relevant parameters, and evolution trends of different scenarios. The main result shows that the participation of general hospitals is crucial to the construction of the family doctor service; that is, to develop the family doctor service, the government should focus on financial compensation for general hospitals rather than for family doctors.We further concluded that the compensation mechanism of contracted services plays a vital role in attracting physicians’ participation; thus, policymakers should consider these in different stages of the promotion of the family doctor service

A RETURN ON INVESTMENT ANALYSIS OF USING HEALTH INFORMATION TECHNOLOGY IN THE COURSE OF ADMISSION DECISIONS

In light of the ever-growing importance and usability of medical information systems (IS), the healthcare sector has been investing heavily in these technologies in recent years, with the aim of improving decision-making through improved medical processes, reduced costs and integration of medical data. However, these systems are extremely costly. In addition, the overall contribution of these technologies to the medical field is not obvious, especially, in high-stress environments such as emergency departments (EDs). The objective of this research is to explore whether investing in health information technology (HIT) in an ED is financially rewarding in general, and specifically the circumstances under which such an investment is more rewarding and vice versa. A cost-effectiveness analysis served as the selected tool for return on investment (ROI) estimations of certain integrative medical IS that serves seven main hospitals in Israel. We evaluated the overall profitability of this medical IS, by balancing the quality gained from information (retrieved from medical IS) against the costs of providing this information. The results of the cost-effectiveness analysis show that our specific medical cases of chest pain received a clear cost-effective reading since the results (ΔQuality/ΔCosts) were lower than the range of all common threshold values. Furthermore, the use of HIT in the ED improved the quality units per patient for each chosen admission decisions The findings of this study may also contribute to policy makers in the healthcare sector regarding the advisability of investing in such systems

Childhood Cancer in Ethiopia: Treatment Abandonment Rate and the Cost and Cost-Effectiveness of Service Delivery

Bakgrunn: I motsetning til mange typer kreft hos voksne og eldre, kan kreft hos barn ofte helbredes, selv i land med begrensede ressurser, hvis kreften diagnostiseres tidlig og behandles riktig. Et barns diagnose med kreft kan bety en god prognose for helbredelse eller nesten sikker død avhengig av hvor i verden barnet bor. I gjennomsnitt overlever åtte av ti barn med kreft i høyinntektsland, mens bare to til tre av ti overlever i lav- og mellominntektsland. Denne drastiske forskjellen i overlevelsesrater kan forklares med lav tilgjengelighet av pediatriske onkologiske tjenester, utilstrekkelig trent personell, dårlig kvalitet, suboptimal tilgjengelighet av støttebehandling, sen presentasjon, mangel på sosial støtte og høy andel behandlingsavbrudd. For å endre dette har mange store organisasjoner oppfordret til å gi kontroll av barnekreft høyere prioritet på globalt og landnivå. I den nylig reviderte etiopiske grunnleggende helsetjenestepakken er intervensjoner for kontroll av barnekreft (som diagnose og behandling) gitt middels og lav prioritet, et stort tilbakeslag for arbeidet med å kontrollere barnekreft i Etiopia. Denne avhandlingen har som mål å fremskaffe ny kunnskap om kostnadene og effekten av barnekreftomsorg i Etiopia, for å informere revisjonen av den grunnleggende helsetjenestepakken, og gi ny kunnskap om omfanget og risikofaktorene for behandlingsavbrudd. Avbrutt behandling er en av de viktigste årsakene til behandlingssvikt og dårlig overlevelse i lavinntektsland. Metoder: Vi gjennomførte tre studier for å nå målene med denne avhandlingen. Den første studien (artikkel I) vurderte omfanget av og risikofaktorene for behandlingsavbrudd i Etiopia fra et helsepersonell perspektiv. Denne tverrsnitts studien ble utført fra i 2021 i tre av de fire pediatriske onkologisentrene i Etiopia på tidspunktet for datainnsamlingen. Vi brukte et validert, semi-strukturert spørreskjema utviklet av International Society of Pediatric Oncology Abandonment Technical Working Group og inkluderte alle helsepersonell (leger, sykepleiere og sosialarbeidere) (N = 38) ved disse sentrene som hadde mer enn ett år erfaring med tjenesteyting innen barnekreft. Den andre studien (artikkel II) estimerte kostnadene ved å drive en pediatrisk onkologienhet fra et helsetjenesteperspektiv ved å undersøke den første og mest etablerte pediatriske onkologienheten i Etiopia: Tikur Anbessa Specialized Hospital (TASH) i Addis Abeba, hovedstaden. Vi brukte historiske årlige kostnadsdata fra TASH fra perioden 8. juli 2018 til 7. juli 2019 og estimerte kostnadene for hele den pediatriske onkologiske enheten ved å bruke en kombinert beregningsmetode av som tar hensyn til makrokostnad (ovenfra og ned) og mikrokostnad (nedenfra og opp). De direkte kostnadene til den pediatriske onkologiske enheten (helsepersonell, legemidler, forsyninger, medisinsk utstyr), kostnader i andre relevante kliniske avdelinger og overheadkostnaden ble lagt sammen for å estimere de totale årlige kostnadene ved å drive enheten. Videre estimerte vi enhetskostnader for spesifikke barnekreftformer. I den tredje studien (Artikkel III), basert på kostnadsstudiens funn samt effektestimater fra land som ligner, estimerte vi den totale kostnadseffektiviteten ved å drive en pediatrisk onkologisk enhet ved TASH. Vi bygde en beslutningsanalytisk modell – et beslutningstre – for å estimere kostnadseffektiviteten ved å drive en pediatrisk onkologisk enhet sammenlignet med et gjøre-ingenting-scenario (ingen pediatrisk onkologibehandling) fra et helsetjeneste perspektiv. Vi diskonterte både kostnader og effekter til nåverdi med en diskonteringsrente på 3 %, og valgte en livstidshorisont for effekt og behandlingsvarighet to år for kostnader. Det primære resultatet var inkrementelle kostnader i amerikanske dollar per avverget sykdomsjustert leveår (DALY), og vi brukte en betalingsvillighet (WTP)-terskel på 50 % av etiopisk BNP per innbygger (477 amerikanske dollar i 2019) ). Usikkerhet angående studiens resultater ble utforsket ved hjelp av standard sensitivitetsanalyser. Resultater: Den gjennomsnittlige behandingsavbruddsraten i Etiopia, vurdert av helsepersonell, var 34 % (standardfeil: 2,5 %). Risikoen for å avbryte behandlingen var avhengig av typen kreft (f.eks. høy for beinsarkom og hjernesvulst), behandlingsfasen og behandlingsresultatet. Den høyeste risikoen ble observert under perioder med vedlikeholdsbehandling, ved behandlingssvikt eller tilbakefall for akutt lymfatisk leukemi og under pre- eller postkirurgisk fase for Wilms tumor- og beinsarkom. De viktigste risikofaktorene i Etiopia inkluderte høye omsorgskostnader, brukernes lave økonomiske status, lange reisetider til behandlingssentre, lange ventetider, tro på at kreft er uhelbredelig og lav offentlig oppmerksomhet om barnekreft. Faktorene som ble funnet å spille en viktig rolle i å påvirke behandlingsavbrudd inkluderer underernæring, bivirkninger og toksisitet av behandlingen, smertefulle diagnostiske og terapeutiske prosedyrer, utilstrekkelig kommunikasjon fra helsepersonell, en preferanse for komplementær og alternativ medisin, og sterk religiøs tro. Den estimerte årlige totale kostnaden for å drive en pediatrisk onkologisk enhet (2019-dollar) var 776 060 amerikanske dollar (tilsvarer 577 dollar per behandlet barn) og varierte fra 469 til 1085 dollar per behandlet barn i den scenariobaserte sensitivitetsanalysen. Legemidler og rekvisita og helsepersonell utgjorde henholdsvis 33 % og 27 % av totalkostnaden, mens poliklinikken og døgnavdelingen sto for henholdsvis 37 % og 63 % av kostnadene. Den årlige kostnaden per behandlet barn varierte fra 322 til 1313 dollar avhengig av type barnekreft. Den inkrementelle kostnaden og DALYs avverget per barn behandlet i TASHs pediatriske onkologiske enhet var henholdsvis 876 dollar og 2,4 DALYs, sammenlignet med ingen pediatrisk onkologisk behandling. Det inkrementelle kostnadseffektivitetsforholdet ved å drive en pediatrisk onkologisk enhet var 361 dollar per DALY avverget, og det var kostnadseffektivt i 93 % av 100 000 Monte Carlo-simuleringer ved en WTP-terskel på 477 dollar. Konklusjoner: Den opplevde behandingsavbruddsraten i Etiopia var høy, og risikoen for avbrudd varierte avhengig av krefttype, behandlingsfase og behandlingsresultat. De viktigste risikofaktorene for å avbryte behandling i Etiopia er høye omsorgskostnader, lav økonomisk status for husholdninger, lang reisetid til behandlingssentre, lange ventetider, tro på at kreft er uhelbredelig og lav offentlig bevissthet om barnekreft. Selv om andre studier rapporterer liknende funn, er det rapporterte nivået for flere av risikofaktorene forskjellige i Etiopia sammenliknet med andre liknende land. Tiltak for å redusere behandlingsavbrudd bør bygge på kunnskap om identifiserte risikofaktorer og tiltakenes effekt, gjennomførbarhet og realistiske kostnadsrammer. Tilbudet av krefttjenester for barn ved bruk av en spesialisert onkologisk enhet er sannsynligvis kostnadseffektive og innenfor realistiske kostnadsrammer i Etiopia, i det minste for krefttyper som er lett å behandle i sentre med minimal til moderat kapasitet. Vi anbefaler å revurdere prioriteringsnivået for behandling av barnekreft i gjeldende grunnleggende helsetjenestepakke.Background: Unlike adult cancer, childhood cancer is highly curable, even in resource-constrained settings, if diagnosed early and treated effectively. However, a child’s diagnosis with cancer can mean a good prognosis of cure or almost certain death depending on where in the world the child lives. On average, the overall survival of children with cancer is eight out of ten in high-income countries, while only two to three of ten survive in low- and middle-income countries (LMICs). This drastic difference in survival rates can be explained by the unavailability of pediatric oncology services, inadequately trained personnel, poor service quality, suboptimal availability of supportive care, late presentation, lack of social support, and high treatment abandonment rate in LMICs. To change this reality, a global call and solidarity movement has emerged to make childhood cancer control a major public health priority at the global and country levels. In the recently revised Ethiopian Essential Health Services Package (EHSP), however, childhood cancer control interventions (such as diagnosis and treatment) are given medium and low priority, a major setback to efforts to control childhood cancer in Ethiopia. Therefore, this thesis aims to inform the revision of the EHSP by providing evidence on the cost and cost-effectiveness of childhood cancer care (diagnosis and treatment) in Ethiopia and by assessing the magnitude and influencing risk factors of treatment abandonment, which is the major cause of treatment failure and poor survival in low-income countries. Methods: We conducted three studies to pursue the aims of this thesis. The first study (Paper I) assessed the magnitude and influencing risk factors of childhood cancer treatment abandonment in Ethiopia from the health care provider perspective. This cross-sectional study was conducted from September 5–22, 2021 in three of the four pediatric oncology centers in Ethiopia at the time of the data collection. We used a validated, semi-structured questionnaire developed by the International Society of Pediatric Oncology Abandonment Technical Working Group and included all health care professionals (physicians, nurses, and social workers) (N = 38) at these centers who had more than one year of experience in childhood cancer service provision. The second study (Paper II) estimated the cost of running a pediatric oncology unit from a provider perspective by examining the first and better-established pediatric oncology unit in Ethiopia at Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa, the capital. We used TASH’s historical annual cost data from 8 July 2018 through 7 July 2019 and estimated the cost of running the pediatric oncology unit using a mixed costing approach of macro-costing (top down) and micro-costing (bottom up). The direct costs of the pediatric oncology unit (HR, drugs, supplies, medical equipment), costs in other relevant clinical departments, and the overhead cost share were aggregated to estimate the total annual cost of running the unit. Furthermore, we estimated unit costs for specific childhood cancers. In the third study (Paper III), building on the costing study’s findings (Paper II) as well as effectiveness estimates from similar settings, we estimated the overall cost-effectiveness of running a pediatric oncology unit at TASH. We built a decision-analytic model—a decision tree—to estimate the cost-effectiveness of running a pediatric oncology unit compared to a do-nothing scenario (no pediatric oncology care) from a health care provider perspective. We discounted both costs and effects to their present value at a 3% discount rate, taking a lifetime time horizon for effect and the treatment duration (two years) for costs. The primary outcome was incremental cost in US dollars (USD) per disability-adjusted life year (DALY) averted, and we used a willingness-to-pay (WTP) threshold of 50% of the Ethiopian GDP per capita (USD 477 in 2019). Uncertainty regarding the study’s results was explored using one-way and probabilistic sensitivity analyses. Results: The perceived mean abandonment rate in Ethiopia was 34% (standard error: 2.5%). The risk of treatment abandonment depended on the type of cancer (e.g., high for bone sarcoma and brain tumor), the treatment phase, and the treatment outcome. The highest risk was observed during maintenance, treatment failure, or relapse for acute lymphoblastic leukemia and during the pre- or post-surgical phase for Wilms tumor and bone sarcoma. The major influencing risk factors in Ethiopia included high cost of care, users’ low economic status, long travel times to treatment centers, long waiting times, belief in the incurability of cancer, and poor public awareness of childhood cancer. The factors that were found to play an important role in influencing treatment abandonment include undernourishment, the adverse effects and toxicity of treatment, painful diagnostic and therapeutic procedures, insufficient communication by health care professionals, a preference for complementary and alternative medicine, and strongly held faith or religious beliefs. The estimated annual total cost of running a pediatric oncology unit (8 July 2018–7 July 2019) was USD 776,060 (equivalent to USD 577 per treated child) and ranged from USD 469 to USD 1,085 per treated child in the scenario-based sensitivity analysis. Drugs and supplies and HR accounted for 33% and 27% of the total cost, respectively, while the outpatient and inpatient departments accounted for 37% and 63% of the cost, respectively. The annual cost per treated child ranged from USD 322 to USD 1,313 depending on the type of childhood cancer. The incremental cost and DALYs averted per child treated in TASH’s pediatric oncology unit were USD 876 and 2.4, respectively, compared to no pediatric oncology care. The incremental cost-effectiveness ratio of running a pediatric oncology unit was USD 361 per DALY averted, and it was cost-effective in 90% of 100,000 Monte Carlo simulations at a USD 477 WTP threshold. Conclusions: The perceived abandonment rate in Ethiopia was high, and the risk of abandonment varied according to type of cancer, phase of treatment, and treatment outcome. The major influencing risk factors for treatment abandonment in Ethiopia are the high cost of care, low economic status of households, long travel time to treatment centers, long waiting times, belief in the incurability of cancer, and poor public awareness of childhood cancer. Although other studies report a great similarity of influencing risk factors, the reported level of influence for some risk factor differs in Ethiopia from that in similar settings. Therefore, mitigation strategies to reduce the abandonment rate should identify specific risk factors and prioritize strategies based on their level of influence, effectiveness, feasibility, and affordability. The provision of pediatric cancer services using a specialized oncology unit is most likely cost-effective and affordable in Ethiopia, at least for easily treatable cancer types in centers with minimal to moderate capability. We recommend reassessing the priority level of childhood cancer treatment in the current EHSP.Doktorgradsavhandlin