Quality Services, Better Outcomes: A Quality Framework for Achieving Outcomes.

The Childhood Development Initiative (CDI) is an innovative, community based response to a comprehensive consultation process undertaken in Tallaght West. Working with a wide range of locally established service providers, CDI is delivering services to children and families which meet identified needs. Etch of these is being rigorously evaluated, and considerable attention is being given to quality assurance, promotion of reflective practice, and professional training and support. The insights gained, and techniques developed during this process are central to delivering high quality services with the view to improving our understanding of what enables children to meet their potential, gain their developmental milestones within appropriate timeframes and become healthy and active citizens. This Workbook describes key processes relating to practice, organisational culture and systems change which support the implementation of evidence-based and evidence-informed programmes and practices. From CDI's experience, implementing evidence-based programmes not only requires specific structures and processes in place to support programme implementation and fidelity (e.g. training, coaching, and supervision) but also necessities a focus on the more generic aspects of delivering quality services (e.g. engaging in reflective practice in order to promote and maintain fidelity to a programme). The Workbook also addresses some fundamental areas in relation to monitoring and evaluation as a way of determining whether an intervention was effective or not. In effect, this Workbook hopes to explain the 'what', 'why', 'how' and 'did we?' of evidence-based practice. The Workbook is intended to provide readers with a comprehensive introduction to both the shared language and concepts underpinning the science and practice of implementation. It complements the 'What Works Process' guide published by the Centre for Effective Services (CES, 2011) which supports services in assessing how effective they are in improving outcomes for children and helps them to think about what works

Pay Attention: Children’s Understanding, Experience and Attitudes to Having a Say in Their Everyday Lives

Paying attention to children’s participation rights has gained momentum during the late 20th century. The study explored the views and experiences of children between 10 and 12 years in relation to ‘children having a voice in matters that affect them and their views will be given due weight in accordance with their age and maturity’ 10 years on from the National Children’s Strategy (NCS, 2000). Focus groups were employed to carry out the research. Children in the study demonstrated a limited understanding of the concept of rights. Children in this study provided a clear message that they wish to have a voice and that they often feel that they are not listened to. Children taking part articulated the reasons why they think they should be listened to. Children identified that adults play an important role in supporting children to exercise their right to have a voice. Children’s views on the reasons or factors why adults do not listen to them are interesting and unforeseen. The findings are discussed with reference to theories on childhood and children’s rights, past research on children’s rights and current practice. Gaps between policy and practice in recognising children’s rights, adults’ status as decision makers and unequal childparent interactions may all interact to constrain children’s experiences of exercising their right to a voice consistently

An economic analysis of money follows the patient

Introduction: As part of the proposed changes to re-design the Irish health-care system, the Department of Health (money follows the patient—policy paper on hospital financing, 2013b) outlined a new funding model for Irish hospitals—money follows the patient (MFTP). This will replace the existing system which is predominately prospective with hospitals receiving a block grant per annum. MFTP will fund episodes of care rather than hospitals. Thus, hospital revenue will be directly linked to activity [activity-based funding (ABF)]. Theory and literature review: With ABF there is a fundamental shift to a system where hospitals generate their own income and this changes incentive structures. While some of these incentives are intended (reducing cost per case and increasing coding quality), others are less intended and less desirable. As a result, there may be reductions in quality, upcoding, cream skimming and increased pressure on other parts of the health system. In addition, MFTP may distort health system priorities. There are some feasibility concerns associated with the implementation of MFTP. Data collection, coding and classification capacity are crucial for its success. While MFTP can build on existing systems, significant investment is required for its success. This includes investment in coding and classification, infrastructure, skills, IT, contracting, commissioning, auditing and performance monitoring systems. Conclusions: Despite the challenges facing implementers, MFTP could greatly improve the transparency and accountability of the system. Thus if the downside risks are managed, there is potential for MFTP to confer significant benefits to Irish hospital care

Health technology assessment: a primer for ophthalmology

Rising healthcare costs and increasing demands for health care require techniques to choose between competing uses and even rationing of health care. Economic evaluations and health technology assessments are increasingly a means to assess the cost effectiveness of healthcare interventions so as to inform such resource allocation decisions. To date, the adoption of health technology assessments, as a way of assessing cost effectiveness, in ophthalmology has been slower, relative to their implementation in other specialities. Nevertheless, demands for eye services are increasing due to an ageing population. The prevalence of conditions such as glaucoma, cataract, diabetic eye disease and age-related macular degeneration increases with age, and it is predicted that global blindness will triple by 2050. So there is a challenge for ophthalmologists to ensure that they can contribute to, interpret, critically evaluate, and use findings from economic evaluations in their clinical practice. To aid this, this article serves as a primer on the use of health technology assessments to assess cost effectiveness using economic evaluation techniques for ophthalmologists. Healthcare systems face many challenges worldwide – changing demographics and evolution of new technologies are only going to intensify. With this in mind, ophthalmology needs to be ready and able to engage with health economists to prepare, interpret, critically evaluate and use findings of economic evaluations and health technology assessments

Knowledge is power: general practitioners prescribing of new oral anticoagulants in Ireland

Objective: New oral anticoagulants (NOACs) aim to overcome warfarin’s shortcomings, however their pharmacokinetic characteristics make prescribing complex. Thus it is imperative that general practitioners (GPs) are aware of specific treatments so as to maximise their benefits and minimise their pitfalls. This study explores GPs attitudes and experiences with prescribing NOACs in Ireland where, despite clear national prescribing guidelines advocating warfarin as first line therapy, the number of patients being prescribed NOACs for the first time is growing. Results: Using primary data collected from GPs in Ireland the factors influencing the likelihood of a GP initiating a prescription for a NOAC are determined using a probit model. Results indicate 46% of the sample initiated NOAC prescriptions and GP practice size is a significant factor influencing this. Analysis revealed no difference regarding the sources of information considered important amongst GPs when prescribing new drugs. However, there were differences in which factors were considered important when prescribing anticoagulants between initiating and non-initiating NOAC prescribers. The results of this study suggest better utilisation of existing information and education tools for GPs prescribing NOACs and managing NOAC patients is imperative, to ensure the right anticoagulant is prescribed for the right patient at the right time

Economic evaluations for health technologies with an evolving evidence base: a case study of transcatheter aortic valve implantation

The primary aim of this thesis is to investigate the challenges in conducting economic evaluations for medical devices with evolving evidence bases. While economic evaluations for capital projects and medicines are well established in theory and practice, the same cannot be said for novel medical devices. New medical devices are often expensive and rely on scarce evidence for efficacy and cost. This increases uncertainty surrounding their clinical and cost effectiveness. In addition, as fewer formal procedures exist for evaluating devices relative to medicines, evidence bases are weak and health technology assessment agencies are reluctant to make rapid decisions. To address these issues a continuous iterative framework developed and proposed for economic evaluations of medical devices. In this thesis, using Transcatheter Aortic Valve Implantation (TAVI) as a case study, an iterative economic evaluation, employing Bayesian techniques, is developed to investigate how the challenges associated with medical devices can be overcome to produce an efficient and informative economic evaluation. This study is the first to investigate these challenges and identify solutions while conducting an economic evaluation early in a device’s life cycle, using the proposed continuous iterative framework. The consideration of Access with Evidence Development schemes to overcome these challenges and balance access with evidence generation for expensive and novel medical devices, with evolving evidence, is another important contribution of the thesis. Transcatheter Aortic Valve Implantation (TAVI) is a novel treatment for severe Aortic Stenosis for operable and inoperable patients. The iterative economic evaluation concludes that TAVI can be considered cost effective for inoperable patients compared to medical management. There is little value in commissioning new research for continued data collection for this group. However, the continued collection of evidence via the UK TAVI registry as indicated in the National Institute of Clinical Excellence (NICE) guidelines will ensure up to date evidence is available to inform future decisions regarding TAVI in this patient group. For operable patients, the iterative model could not conclude that TAVI was cost effective compared to Aortic Valve Replacement (AVR). However, additional evidence of improved outcomes from TAVI should enhance its cost effectiveness for these patients. The Bayesian value of information analysis indicates that further information on short and long term probability, resource and quality of life parameters is most valuable and the optimal research design for collecting such information is a registry

Obesity, diet quality and absenteeism in a working population

The relationship between workplace absenteeism and adverse lifestyle factors (smoking, physical inactivity and poor dietary patterns) remains ambiguous. Reliance on self-reported absenteeism and obesity measures may contribute to this uncertainty. Using objective absenteeism and health status measures, the present study aimed to investigate what health status outcomes and lifestyle factors influence workplace absenteeism. Cross-sectional data were obtained from a complex workplace dietary intervention trial, the Food Choice at Work Study. Four multinational manufacturing workplaces in Cork, Republic of Ireland. Participants included 540 randomly selected employees from the four workplaces. Annual count absenteeism data were collected. Physical assessments included objective health status measures (BMI, midway waist circumference and blood pressure). FFQ measured diet quality from which DASH (Dietary Approaches to Stop Hypertension) scores were constructed. A zero-inflated negative binomial (zinb) regression model examined associations between health status outcomes, lifestyle characteristics and absenteeism. The mean number of absences was 2·5 (sd 4·5) d. After controlling for sociodemographic and lifestyle characteristics, the zinb model indicated that absenteeism was positively associated with central obesity, increasing expected absence rate by 72 %. Consuming a high-quality diet and engaging in moderate levels of physical activity were negatively associated with absenteeism and reduced expected frequency by 50 % and 36 %, respectively. Being in a managerial/supervisory position also reduced expected frequency by 50 %. To reduce absenteeism, workplace health promotion policies should incorporate recommendations designed to prevent and manage excess weight, improve diet quality and increase physical activity levels of employees