Integrated care across borders: possibilities and complexities

The main purpose of this practice paper is to describe and analyse the possibilities and complexities of integrated health care across borders. First, we portray an ideal scenario for this type of care with a case of patients suffering from rheumatoid arthritis and living in the Dutch-Belgian frontier area. It shows how cross border care enhances continuity of care/tailor-made care and the other way around. Secondly, based on different literature sources, we describe actual regulations on health care across borders. We show that these regulations can be a major hindrance to integrated care. This raises questions on the scope and content of policies directed at both cross border and integrated care

A new instrument to measure high value, cost-conscious care attitudes among healthcare stakeholders: Development of the MHAQ

Background: Residents have to learn to provide high value, cost-conscious care (HVCCC) to counter the trend of excessive healthcare costs. Their learning is impacted by individuals from different stakeholder groups within the workplace environment. These individuals' attitudes toward HVCCC may influence how and what residents learn. This study was carried out to develop an instrument to reliably measure HVCCC attitudes among residents, staff physicians, administrators, and patients. The instrument can be used to assess the residency-training environment. Method: The Maastricht HVCCC Attitude Questionnaire (MHAQ) was developed in four phases. First, we conducted exploratory factor analyses using original data from a previously published survey. Next, we added nine items to strengthen subscales and tested the new questionnaire among the four stakeholder groups. We used exploratory factor analysis and Cronbach's alphas to define subscales, after which the final version of the MHAQ was constructed. Finally, we used generalizability theory to determine the number of respondents (residents or staff physicians) needed to reliably measure a specialty attitude score. Results: Initial factor analysis identified three subscales. Thereafter, 301 residents, 297 staff physicians, 53 administrators and 792 patients completed the new questionnaire between June 2017 and July 2018. The best fitting subscale composition was a three-factor model. Subscales were defined as high-value care, cost incorporation, and perceived drawbacks. Cronbach's alphas were between 0.61 and 0.82 for all stakeholders on all subscales. Sufficient reliability for assessing national specialty attitude (G-coefficient > 0.6) could be achieved from 14 respondents. Conclusions: The MHAQ reliably measures individual attitudes toward HVCCC in different stakeholders in health care contexts. It addresses key dimensions of HVCCC, providing content validity evidence. The MHAQ can be used to identify frontrunners of HVCCC, pinpoint aspects of residency training that need improvement, and benchmark and compare across specialties, hospitals and regions

Out-of-Pocket Costs and Other Determinants of Access to Healthcare for Children with Febrile Illnesses: A Case-Control Study in Rural Tanzania.

To study private costs and other determinants of access to healthcare for childhood fevers in rural Tanzania. A case-control study was conducted in Tanzania to establish factors that determine access to a health facility in acute febrile illnesses in children less than 5 years of age. Carers of eligible children were interviewed in the community; cases were represented by patients who went to a facility and controls by those who did not. A Household Wealth Index was estimated using principal components analysis. A multivariable logistic regression analysis was performed to understand the factors which influenced attendance of healthcare facility including severity of the illness and household wealth/socio-demographic indicators. To complement the data on costs from community interviews, a hospital-based study obtained details of private expenditures for hospitalised children under the age of 5. Severe febrile illness is strongly associated with health facility attendance (OR: 35.76, 95%CI: 3.68-347.43, p = 0.002 compared with less severe febrile illness). Overall, the private costs of an illness for patients who went to a hospital were six times larger than private costs of controls ($5.68 vs.$0.90, p<0.0001). Household wealth was not significantly correlated with total costs incurred. The separate hospital based cost study indicated that private costs were three times greater for admissions at the mission versus public hospital: $13.68 mission vs.$4.47 public hospital (difference $ 9.21 (95% CI: 7.89 -10.52), p<0.0001). In both locations, approximately 50% of the cost was determined by the duration of admission, with each day in hospital increasing private costs by about 12% (95% CI: 5% - 21%). The more severely ill a child, the higher the probability of attending hospital. We did not find association between household wealth and attending a health facility; nor was there an association between household wealth and private cost

Aspects and Challenges of Resource Use Measurement in Health Economics:Towards a Comprehensive Measurement Framework

BACKGROUND: While the methods for conducting health economics research in general are improving, current guidelines provide limited guidance regarding resource use measurement (RUM). Consequently, a variety of methods exists, yet there is no overview of aspects to consider when deciding on the most appropriate RUM methodology. Therefore, this study aims to (1) identify and categorize existing knowledge regarding aspects of RUM, and (2) develop a framework that provides a comprehensive overview of methodological aspects regarding RUM. METHODS: Relevant articles were identified by enrolling a search string in six databases and handsearching the DIRUM database. Included articles were descriptively reviewed and served as input for a comprehensive framework. Health economics experts were involved during the process to establish the framework’s face validity. RESULTS: Forty articles were included in the scoping review. The RUM framework consists of four methodological RUM domains: ‘Whom to measure’, addressing whom to ask and whom to measure; ‘How to measure’, addressing the different approaches of measurement; ‘How often to measure’, addressing recall period and measurement patterns; and ‘Additional considerations’, which covers additional aspects that are essential for further refining the methodologies for measurement. Evidence retrieved from the scoping review was categorized according to these domains. CONCLUSION: This study clustered the aspects of RUM methodology in health economics into a comprehensive framework. The results may guide health economists in their decision making regarding the selection of appropriate RUM methods and developing instruments for RUM. Furthermore, policy makers may use these findings to review study results from an evidence-based perspective. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40273-021-01048-z

Exploring the identification, validation, and categorization of costs and benefits of education in mental health: the PECUNIA project

BackgroundMental health problems can lead to costs and benefits in other sectors (e.g. in the education sector) in addition to the healthcare sector. These related costs and benefits are known as intersectoral costs and benefits (ICBs). Although some ICBs within the education sector have been identified previously, little is known about their extensiveness and transferability, which is crucial for their inclusion in health economics research.ObjectivesThe aim of this study was to identify ICBs in the education sector, to validate the list of ICBs in a broader European context, and to categorize the ICBs using mental health as a case study.MethodsPreviously identified ICBs in the education sector were used as a basis for this study. Additional ICBs were extracted from peer-reviewed literature in PubMed and grey literature from six European countries. A comprehensive list of unique items was developed based on the identified ICBs. The list was validated by surveying an international group of educational experts. The survey results were used to finalize the list, which was categorized according to the care atom.ResultsAdditional ICBs in the education sector were retrieved from ninety-six sources. Fourteen experts from six European countries assessed the list for completeness, clarity, and relevance. The final list contained twenty-four ICBs categorized into input, throughput, and output.ConclusionBy providing a comprehensive list of ICBs in the education sector, this study laid further foundations for the inclusion of important societal costs in health economics research in the broader European context

The Relative Importance of Education and Criminal Justice Costs and Benefits in Economic Evaluations

Objectives Mental and behavioural disorders (MBDs) and interventions targeting MBDs lead to costs and cost savings in the healthcare sector, but also in other sectors. The latter are referred to as intersectoral costs and benefits (ICBs). Interventions targeting MBDs often lead to ICBs in the education and criminal justice sectors, yet these are rarely included in economic evaluations. This study aimed to investigate the attitudes held by health economists and health technology assessment experts towards education and criminal justice ICBs in economic evaluations and to quantify the relative importance of these ICBs in the context of MBDs. Methods An online survey containing open-ended questions and two best–worst scaling object case studies was conducted in order to prioritise a list of 20 education ICBs and 20 criminal justice ICBs. Mean relative importance scores for each ICB were generated using hierarchical Bayes analysis. Results Thirty-nine experts completed the survey. The majority of the respondents (68%) reported that ICBs were relevant, but only a few (32%) included them in economic evaluations. The most important education ICBs were “special education school attendance”, “absenteeism from school”, and “reduced school attainment”. The most important criminal justice ICBs were “decreased chance of committing a crime as a consequence/effect of mental health programmes/interventions”, “jail and prison expenditures”, and “long-term pain and suffering of victims/victimisation”. Conclusions This study identified the most important education and criminal justice ICBs for economic evaluations of interventions targeting MBDs and suggests that it could be relevant to include these ICBs in economic evaluations

Exploring the identification, validation, and categorization of the cost and benefits of criminal justice in mental health: the PECUNIA project

Background Mental health disorders and their treatments produce significant costs and benefits in both healthcare and non-healthcare sectors. The latter are often referred to as intersectoral costs and benefits (ICBs). Little is known about healthcare-related ICBs in the criminal justice sector and how to include these in health economics research. Objectives The triple aim of this study is (i) to identify healthcare-related ICBs in the criminal justice sector, (ii) to validate the list of healthcare-related ICBs in the criminal justice sector on a European level by sector-specific experts, and (iii) to classify the identified ICBs. Methods A scientific literature search in PubMed and an additional grey literature search, carried out in six European countries, were used to retrieve ICBs. In order to validate the international applicability of the ICBs, a survey was conducted with an international group of experts from the criminal justice sector. The list of criminal justice ICBs was categorized according to the PECUNIA conceptual framework. Results The full-text analysis of forty-five peer-reviewed journal articles and eleven grey literature sources resulted in a draft list of items. Input from the expert survey resulted in a final list of fourteen unique criminal justice ICBs, categorized according to the care atom. Conclusion This study laid further foundations for the inclusion of important societal costs of mental health-related interventions within the criminal justice sector. More research is needed to facilitate the further and increased inclusion of ICBs in health economics research

An Online Health Prevention Intervention for Youth with Addicted or Mentally Ill Parents:Experiences and Perspectives of Participants and Providers from a Randomized Controlled Trial

Background: Mental illnesses affect many people around the world, either directly or indirectly. Families of persons suffering from mental illness or addiction suffer too, especially their children. In the Netherlands, 864,000 parents meet the diagnostic criteria for a mental illness or addiction. Evidence shows that offspring of mentally ill or addicted parents are at risk for developing mental disorders or illnesses themselves. The Kopstoring course is an online 8-week group course with supervision by 2 trained psychologists or social workers, aimed to prevent behavioral and psychological problems for children (aged 16 to 25 years) of parents with mental health problems or addictions. The course addresses themes such as roles in the family and mastery skills. An online randomized controlled trial (RCT) was conducted to assess the effectiveness of the Kopstoring course. Objective: The aim was to gain knowledge about expectations, experiences, and perspectives of participants and providers of the online Kopstoring course. Methods: A process evaluation was performed to evaluate the online delivery of Kopstoring and the experiences and perspectives of participants and providers of Kopstoring. Interviews were performed with members from both groups. Participants were drawn from a sample from the Kopstoring RCT. Results: Thirteen participants and 4 providers were interviewed. Five main themes emerged from these interviews: background, the requirements for the intervention, experience with the intervention, technical aspects, and research aspects. Overall, participants and providers found the intervention to be valuable because it was online; therefore, protecting their anonymity was considered a key component. Most barriers existed in the technical sphere. Additional barriers existed with conducting the RCT, namely gathering informed consent and gathering parental consent in the case of minors. Conclusions: This study provides valuable insight into participants' and providers' experiences and expectations with the online preventive intervention Kopstoring. It also sheds light on the process of the online provision of Kopstoring and the accompanying RCT. The findings of this study may partly explain dropout rates when delivering online interventions. The change in the (financial) structure of the youth mental health care system in the Netherlands has financial implications for the delivery of prevention programs for youth. Lastly, there are few RCTs that assess the effectiveness and cost-effectiveness of online prevention programs in the field of (youth) mental health care and not many process evaluations of these programs exist. This hampers a good comparison between online interventions and the expectations and experiences of the participants and providers