Avoiding admissions : the most cost effective delivery of acute care to residents of aged-care facilities in the Hutt Valley : a thesis presented in partial fulfilment of the requirements for the degree of Masters of Business Studies in Management at Massey University

The highest annual costs of health care occur in the last one to two years of life. The most expensive part of health care provision during this period is aged-residential care. As residents of aged-care facilities are frail and suffer from chronic illness, periodic medical care is required. For residents of aged-care facilities in the Hutt Valley, this medical intervention is either provided on-site with the assistance of the contract general practitioner or the resident is acutely admitted to the Hutt Hospital. Such admissions incur a significant cost to the District Health Board, which continues to pay for the aged-residential care bed for up to 21 days in any one calendar year even if a bed is vacated for an acute hospitalisation. This study examined acute admission data of aged-care facility residents admitted into Hutt Hospital during 2003 from 1 Dec 2002 to 30 November 2003. This was compared (the acute admission data) to a census of 18 aged-care facilities in the Hutt Valley to identify the most cost effective delivery of acute care to the residents. Analysis of data collected from the study supported a number of variables that impact on acute admission rates. These variables included attitude of the aged-care facility manager to acute admission, access to registered nursing, facility characteristics and contractual arrangements with general practitioners. Five alternative models of acute care delivery were examined for possible impact on acute admission rates and cost effectiveness. The most cost effective delivery of acute care to residents of aged-care delivery is through a twenty-four hour contractual arrangement with a general practitioner. However, variables such as contractual obligations of aged-care facilities, profit status, staffing configuration and whether a facility also offers other retirement options such as villas impact on acute admission rates and have implications in the development of older persons policy in New Zealand. Health researchers in New Zealand have not explored this area to date. Given the cost to the economy and the future fiscal risk with the increasing number of older people, this is an area that requires urgent research attention

Introduction

An introduction to the first volume of The Elizabeth Bowen Review (2018

Holistic facial composite systems: are they compatible with witness recall?

Facial composite systems offer a particular challenge to human-computer interaction as they must facilitate several cognitively complex tasks and also aid communication between the operator and the witness. This paper presents the findings from a survey conducted with UK police composite operators that explored some of the issues involved in composite construction. A particular emphasis was placed on the information that witnesses report and its compatibility with both the composite system interface and the underlying construction method used by the system

Imagining Autism: Now I see the World

‘Imagining Autism: Now I See the World’ is a film emerging from the University of Kent’s AHRC funded project, in which an interdisciplinary team of drama and psychology researchers pioneered novel ways of interacting with this hard to reach condition and in so doing revealed new insights into what Francesca Happe describes as the ‘extraordinary otherness of the autistic mind’. As a dialogue between documentary film and participatory performance arts, Nicola Shaughnessy (Principal Investigator and Producer) and Sarah Turner (Film Maker) create a window into the imaginative world of autism and the perceptual experience of the participants. As an experimental film artist, Turner sought ‘to keep the documentary real, but to privilege the more feeling space.’ The project’s practical methods facilitated communication (verbal and physical), social interaction (with practitioners and peers) and imagination (pretence and play), the key diagnostic elements in autism. Multisensory scenic “environments” (e.g. forest, arctic, space) functioned as intermedial encounters; the film is similarly positioned between two worlds, a key to an alternative sensuality and a means of imaginatively walking in the shoes of the other. The sub-title (Now I see the World) comes from the words of the boy who is centre-stage, discovering his voice through the microphone and his mother’s testimony closes the film. The participants in the film are co-producers, working through improvisation and intensive interaction with specially trained practitioners. Whilst the impact narrative as reported in the New Scientist ascribes ‘value’ in terms of empirical evidence of efficacy (statistically significant improvements in language, emotion recognition, empathy and socialization), the film’s exploration of the affective journeys for participating children, teachers, and practitioners, articulates complementary perspectives, valuing agency, self-expression and aesthetics

Moral ambiguity in media reports of dying alone

More older people are living alone in the UK, thereby increasing the prospect of dying alone at home. Lone deaths tend to be regarded as bad deaths, in that they contravene notions of accompaniment and open awareness espoused in UK end of life care policies. We describe a media analysis of dying alone conducted in two phases. First, we revisited a previous media analysis to examine whether news reporting of dying alone has changed. Second, we focussed on a single case study to explore how an account of a lone death unfolded during the days following its discovery. We found that dying alone remains a threat to individual and collective moral reputations. However, we also identified reports in which dying alone was presented as acceptable in some circumstances, and as congruent with aspects of a good death. We suggest that dying alone can be made good through media reporting, reflecting the individual choice and autonomy associated with a good death. There is potential for news media to revise cultural scripts of dying, largely based on the experiences of people dying under medical supervision

Angiotensin-Converting Enzyme 2: The First Decade

The renin-angiotensin system (RAS) is a critical regulator of hypertension, primarily through the actions of the vasoactive peptide Ang II, which is generated by the action of angiotensin-converting enzyme (ACE) mediating an increase in blood pressure. The discovery of ACE2, which primarily metabolises Ang II into the vasodilatory Ang-(1-7), has added a new dimension to the traditional RAS. As a result there has been huge interest in ACE2 over the past decade as a potential therapeutic for lowering blood pressure, especially elevation resulting from excess Ang II. Studies focusing on ACE2 have helped to reveal other actions of Ang-(1-7), outside vasodilation, such as antifibrotic and antiproliferative effects. Moreover, investigations focusing on ACE2 have revealed a variety of roles not just catalytic but also as a viral receptor and amino acid transporter. This paper focuses on what is known about ACE2 and its biological roles, paying particular attention to the regulation of ACE2 expression. In light of the entrance of human recombinant ACE2 into clinical trials, we discuss the potential use of ACE2 as a therapeutic and highlight some pertinent questions that still remain unanswered about ACE2

Young people's perspectives on open communication between family members when a parent is dying

Objective: Living with a parent who is approaching the end of life is profoundly troubling for young people. Research indicates that family communication about life-limiting parental illness can influence how young people manage living with dying. In particular, open communication between family members has been shown to be helpful. This paper reports on a study of young people’s experiences of family interaction when a parent is dying and considers the practice of open communication in the context of young people’s involvement in giving and receiving family care. Methods: A narrative approach was employed based on in-depth semistructured interviews with 10 young people (aged 13–21) living with a parent thought to be in the last year of life. Results: Young people’s attitudes toward open communication between family members were more ambivalent and ambiguous than previous research suggests. Parental attempts at open communication were sometimes overlooked by young people, indicating that there may be differences between knowledge given and young people’s acknowledgment of sensitive information. Some young people valued open communication as a signifier of the close relationships between family members, while others wanted to exercise more control over what they knew, when, and how. Young people’s accounts challenged the positioning of young people as passive recipients of information. Young people were active in shaping family communication in their everyday lives, and deliberative acts of speaking or remaining silent were one way in which young people exercised care for themselves and others. Significance of Results: This study extends research on communication within families when a parent has a life-limiting illness and suggests that supporting young people’s agency in determining how they receive information may be more beneficial than promoting open communication between family members

Clinical effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: the CoBalT randomised controlled trial

Background: Only one-third of patients with depression respond fully to treatment with antidepressant medication. However, there is little robust evidence to guide the management of those whose symptoms are 'treatment resistant'.<p></p> Objective: The CoBalT trial examined the clinical effectiveness and cost-effectiveness of cognitive behavioural therapy (CBT) as an adjunct to usual care (including pharmacotherapy) for primary care patients with treatment-resistant depression (TRD) compared with usual care alone.<p></p> Design: Pragmatic, multicentre individually randomised controlled trial with follow-up at 3, 6, 9 and 12 months. A subset took part in a qualitative study investigating views and experiences of CBT, reasons for completing/not completing therapy, and usual care for TRD.<p></p> Setting: General practices in Bristol, Exeter and Glasgow, and surrounding areas.<p></p> Participants: Patients aged 18-75 years who had TRD [on antidepressants for 6 weeks, had adhered to medication, Beck Depression Inventory, 2nd version (BDI-II) score of 14 and fulfilled the International Classification of Diseases and Related Health Problems, Tenth edition criteria for depression]. Individuals were excluded who (1) had bipolar disorder/psychosis or major alcohol/substance abuse problems; (2) were unable to complete the questionnaires; or (3) were pregnant, as were those currently receiving CBT/other psychotherapy/secondary care for depression, or who had received CBT in the past 3 years.<p></p> Interventions: Participants were randomised, using a computer-generated code, to usual care or CBT (12-18 sessions) in addition to usual care.<p></p> Main outcome measures: The primary outcome was 'response', defined as 50% reduction in depressive symptoms (BDI-II score) at 6 months compared with baseline. Secondary outcomes included BDI-II score as a continuous variable, remission of symptoms (BDI-II score of < 10), quality of life, anxiety and antidepressant use at 6 and 12 months. Data on health and social care use, personal costs, and time off work were collected at 6 and 12 months. Costs from these three perspectives were reported using a cost-consequence analysis. A cost-utility analysis compared health and social care costs with quality adjusted life-years.<p></p> Results: A total of 469 patients were randomised (intervention: n = 234; usual care: n = 235), with 422 participants (90%) and 396 (84%) followed up at 6 and 12 months. Ninety-five participants (46.1%) in the intervention group met criteria for 'response' at 6 months compared with 46 (21.6%) in the usual-care group {odds ratio [OR] 3.26 [95% confidence interval (CI) 2.10 to 5.06], p < 0.001}. In repeated measures analyses using data from 6 and 12 months, the OR for 'response' was 2.89 (95% CI 2.03 to 4.10, p < 0.001) and for a secondary 'remission' outcome (BDI-II score of < 10) 2.74 (95% CI 1.82 to 4.13, p < 0.001). The mean cost of CBT per participant was £910, the incremental health and social care cost £850, the incremental QALY gain 0.057 and incremental cost-effectiveness ratio £14,911. Forty participants were interviewed. Patients described CBT as challenging but helping them to manage their depression; listed social, emotional and practical reasons for not completing treatment; and described usual care as mainly taking medication.<p></p> Conclusions: Among patients who have not responded to antidepressants, augmenting usual care with CBT is effective in reducing depressive symptoms, and these effects, including outcomes reflecting remission, are maintained over 12 months. The intervention was cost-effective based on the National Institute for Health and Care Excellence threshold. Patients may experience CBT as difficult but effective. Further research should evaluate long-term effectiveness, as this would have major implications for the recommended treatment of depression.<p></p&gt

Caring to the end: exploring the family lives of young people with a parent at the end of life

This thesis reports on an in-depth, qualitative study of the family lives of young people with a parent at the end of life. Family is an important concept in end of life care; the support and comfort of family members is thought to be valued by people at the end of life, and the presence of family is widely understood as essential to a ‘good death’. However, attempts to interrogate what is meant by ‘family’ in these circumstances have been limited. Research studies in psycho-oncology and health sciences have tended to substitute one adult as a proxy for family. Consequently, little is known about young people’s experiences of living with dying. This study employed a multiple perspectives methodology to privilege the views of young people whilst taking into account the familial and wider social context in which young people live. The study is based on semi-structured interviews with ten young people (aged 13-21) with a parent in the last year of life. In addition, five family members were interviewed, each of whom was nominated by a young person. Young people’s accounts were analysed using the voice-centred relational method, a narrative approach involving multiple readings of a transcript to illuminate different aspects of the young person’s account. The narratives of family members were used to support an analysis of how young people understand and experience the relational constructs of family and care. The results and discussion of the study findings are presented according to the three major subject areas of family, care and resources. The meaning, practice and moral significance of family and of care in the everyday lives of young people are examined in the light of wider social discourses on young people’s involvement in care and on ‘doing family’, particularly in the context of end of life care. Young people in the study talked about family in terms of presence, closeness and care; meanings that conflicted with their everyday experiences of absence, distance and loss. The acknowledgement that some family members were unwilling or unable to be there was troubling for young people and disrupted their sense of belonging to a proper family. In particular, the limited ability of parents to be there as a consequence of parental illness challenged the moral imperative for family to put the needs of children first. Instead, the need to provide care for a parent presented families with a new moral imperative to care for the dying. Young people wanted to be there for their parent; providing care was thus one response to getting on with everyday life. Furthermore, in caring for others, young people also cared for themselves by ensuring that their parent remained with them for as long as possible. Friends were named as the most important source of support for young people. Many young people had little contact with service providers, and those who had received support were sometimes ambivalent about its effectiveness. Most young people were able to articulate a future for themselves beyond the death of their parent, and this future narrative contributed a sense of meaning and purpose to their lives in the present. This study adds to current understandings of living with a parent at the end of life by applying a sociological lens to draw attention to the interpersonal and wider social factors that impact on young people’s experiences of living with dying. I conclude that, whilst living with dying is undoubtedly troubling at times, there is also a mundanity seldom acknowledged in the literature in that young people accommodated their experiences in and through the everyday routines and practices of family life. Research, policy and practice in end of life care may benefit from more emphasis on the relational and often lengthy experience of living with dying, and on factors that may help to promote a good dying for all family members, including young people