PUBLIC AND PRIVATE UTILISATION OF IN-PATIENT BEDS IN IRISH ACUTE PUBLIC HOSPITALS. ESRI Research Bulletin 2010/4/5

Health care systems in many developed countries have services financed and provided by both public and private sectors. In Ireland, though, the public/private mix is atypical: a private patient can be treated in an acute public hospital and seen by a consultant who may also treat public patients within the same hospital. Nationally, one in five beds in acute public hospitals is designated for use by private patients and existing legislation restricts accommodation of a private patient in a public-designated bed. Yet there are concerns that acute public hospitals may sidestep such restrictions on their private practice, resulting in public hospital resources potentially being diverted away from public patients towards their private counterparts. Indeed, Irish providers face financial incentives which favour the treatment of private patients. Consultants are rewarded on a fee-for-service basis for private care, but receive a salary for public practice. Public hospitals, meanwhile, receive a fixed daily payment for every private patient in a private bed. Added to these financial incentives is an increased opportunity to engage in private practice due to the substantial recent growth in private health insurance subscribers

Equity in the utilization of hospital in-patient services in Ireland: an improved approach to the measurement of health need and differential cost. ESRI working paper no. 19, n.d.

Hospital services in Ireland have developed into a complex mixture of public and private provision with private patients being treated in public as well as private hospitals. This interweaving of public and private medicine is driven to a large extent by the large proportion of the population covered by health insurance which has grown from 4% in 1960 to over 50% by 2004. This situation has led to concerns that hospital care is not available to all on the basis of need alone but is substantially influenced by personal circumstances. Previous research on Irish hospitals found that utilisation was neutral across the income distribution controlling for health status – i.e., there was essentially equal treatment for equal need irrespective of income. It could be argued however that these analyses did not properly control for health status as those in lower income groups can be shown to have a lower health status within the same response categories within social surveys. Similarly, previous research has also assumed that treatment costs were identical across groups. In this paper we derive a new measure of health – the ‘Ill Health Index’ using three different health indicators and obtain information on differential costs of treatment across groups. We find that both those with medical insurance and those with medical cards are more likely to use hospital services. The costs of these services are also significantly higher for these groups. Comparison of measures of equity for inpatient utilisation and inpatient costs shows that costs are more pro-poor, but a decomposition of the distribution of hospital costs standardising for health needs shows that higher income groups actually use hospital services more and cost more for the same level of health than lower income groups

How Local is Hospital Treatment? An Exploratory Analysis of Public/Private Variation in Location of Treatment in Irish Acute Public Hospitals. ESRI WP237. May 2008

This paper undertakes an exploratory examination of the factors that affect where patients receive treatment from Irish acute public hospitals, with particular regard to the influence of patients’ public/private status. National univariate statistics indicate that private discharged patients are slightly more likely to be treated outside their county of residence than their public counterparts. A multivariate model necessarily estimated at the county level provides indirect support for this finding for the category of day patients, but not for planned and emergency in-patients. The effects of the other patient characteristics also varied across the three models, although there was consistency in the impact of supply-side factors, such as the type and availability of services. As there appears to be some tendency for private day patients to have a slightly greater propensity to travel for acute public hospital treatment, further research is required to identify the reasons for this, as well as the consequences for public and private patients resident in the source and destination counties

The Impact of Flexible Working Arrangements on Work-Life Conflict and Work Pressure in Ireland. ESRI WP192. April 2007

The impetus for this study arose from the need to upgrade the case mix measure of choice in use at the national level in Ireland. Since 1993, various versions of the DRG grouper supported by the Health Care Financing Administration (HCFA) had been in use in Ireland. With improvements in available data, together with developments in the range and quality of alternative groupers available, it was considered timely to test performance of the alternative options on discharge abstract data for Irish hospitals. The groupers selected for testing included four versions of the Australian Refined (AR) DRGs, the AP DRGs (V18.0), CMS DRGs (V20) and IR DRGs (V1.2). Results for the HCFA DRGS (V16.0) were also included for purposes of compariso

PROJECTING THE IMPACT OF DEMOGRAPHIC CHANGE ON THE DEMAND FOR AND DELIVERY OF HEALTH CARE IN IRELAND. RESEARCH SERIES NUMBER 13 OCTOBER 2009

Primary care is often the first point of contact with the health care system for people requiring care. Primary care is often thought synonymous with general practitioners, but actually encompasses a large range of different professionals and services including nurses/midwives; physiotherapists; occupational therapists; dentists; opticians; chiropodists; psychologists and pharmacists. The list is not exhaustive, but still gives an indication of the wide range of services that can be grouped under the general heading of primary care. Nonetheless, GPs do have a core part to play in primary care as well as performing the role of ‘gate keeper’ to other health services such as accident and emergency or outpatient care in hospitals. The balance of treatment and referral between general practice and secondary care is, therefore, a very important issue and it has been argued that the under development of primary care services in Ireland in recent decades has contributed, and indeed, may be the most important reason, for the over-crowding of accident and emergency services and long waiting lists for elective procedures in Irish health care (Layte et al., 2007b; Tussing and Wren, 2006)

Using an e-Delphi technique in achieving consensus across disciplines for developing best practice in day surgery in Ireland

Background: The benefits of day surgery are supported internationally by the provision of standards. However, standards from one health jurisdiction are not readily transferable to others as national health strategy, policy and funding are influencing factors. Objective: To determine, through consensus from experts in day surgery, a list of best practice statements for day surgery in Ireland. Methods: A three round e-Delphi technique. Professionals in surgery, anaesthesia, nursing and management involved in day surgery across all hospitals in Ireland were invited to participate as the expert panel. In round 1 a list of proposals for best practice were obtained from panel members. In round 2 experts were asked to rank each statement according to their importance on a nine point scale (1 = not important, 9 = high importance) using an online questionnaire. Consensus was set at 70%, meaning the items that 70% of people deemed to be important were carried over to round 3. A repeat online questionnaire was conducted with the remaining statements in round 3. Results: Round 1 provided 261 statements. These were grouped and reduced to 62 statements for ranking. Following the iterative process over the subsequent two rounds a final list of 40 statements were developed and grouped into six thematic areas. Conclusion: By using an e-Delphi process of gaining consensus among experts working in day surgical services, a list of best practice statements were developed

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance

INTRODUCTION Investment in Africa over the past year with regard to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing has led to a massive increase in the number of sequences, which, to date, exceeds 100,000 sequences generated to track the pandemic on the continent. These sequences have profoundly affected how public health officials in Africa have navigated the COVID-19 pandemic. RATIONALE We demonstrate how the first 100,000 SARS-CoV-2 sequences from Africa have helped monitor the epidemic on the continent, how genomic surveillance expanded over the course of the pandemic, and how we adapted our sequencing methods to deal with an evolving virus. Finally, we also examine how viral lineages have spread across the continent in a phylogeographic framework to gain insights into the underlying temporal and spatial transmission dynamics for several variants of concern (VOCs). RESULTS Our results indicate that the number of countries in Africa that can sequence the virus within their own borders is growing and that this is coupled with a shorter turnaround time from the time of sampling to sequence submission. Ongoing evolution necessitated the continual updating of primer sets, and, as a result, eight primer sets were designed in tandem with viral evolution and used to ensure effective sequencing of the virus. The pandemic unfolded through multiple waves of infection that were each driven by distinct genetic lineages, with B.1-like ancestral strains associated with the first pandemic wave of infections in 2020. Successive waves on the continent were fueled by different VOCs, with Alpha and Beta cocirculating in distinct spatial patterns during the second wave and Delta and Omicron affecting the whole continent during the third and fourth waves, respectively. Phylogeographic reconstruction points toward distinct differences in viral importation and exportation patterns associated with the Alpha, Beta, Delta, and Omicron variants and subvariants, when considering both Africa versus the rest of the world and viral dissemination within the continent. Our epidemiological and phylogenetic inferences therefore underscore the heterogeneous nature of the pandemic on the continent and highlight key insights and challenges, for instance, recognizing the limitations of low testing proportions. We also highlight the early warning capacity that genomic surveillance in Africa has had for the rest of the world with the detection of new lineages and variants, the most recent being the characterization of various Omicron subvariants. CONCLUSION Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve. This is important not only to help combat SARS-CoV-2 on the continent but also because it can be used as a platform to help address the many emerging and reemerging infectious disease threats in Africa. In particular, capacity building for local sequencing within countries or within the continent should be prioritized because this is generally associated with shorter turnaround times, providing the most benefit to local public health authorities tasked with pandemic response and mitigation and allowing for the fastest reaction to localized outbreaks. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century