THE ORGANISATION OF HEALTHCARE IN IRELAND: SOME …stephenkinsella.net/WordPress/wp-content/uploads/2010/10/GMS_T… · TWITTER FOLLOWERS,

THE ORGANISATION OF HEALTHCARE IN IRELAND:

SOME CRITICAL REFLECTIONSStephen Kinsella, UL

GEMS Research Seminar Series 2011

TONIGHTA Straw Poll~History~Present ‘reality’~Complex Systems

Theory~Research on Unit Costs~Recommendations for reform

BUT FIRST. A STRAW POLL. 1776 TWITTER FOLLOWERS, <10 MINS

Q: WHAT'S THE WORST THING ABOUT THE IRISH HEALTH SERVICE?

@stephenkinsella That Mary Harney is in charge of it. Or else 2 tier system and co-location jointly at the top.

@stephenkinsella that it doesn't exist

@stephenkinsella overmanagement. think there are 3 managers for every health professional in some hospitals. will look for source for that

@stephenkinsella The soul-destroying thing is that money - a lot of money - has been spent., but neither on health nor service.


@stephenkinsella The cult of managerialism over the practice of medicine

@stephenkinsella evrything still runs on paper files. totally inefficient and anti-productive

@stephenkinsella The formal recognition of a 2-tier system, which really stretches back to claiming VHI relief against tax, is at its core.

@stephenkinsella That it took me the same length of time to get a knee op private as it would have taken if I'd been public!


@stephenkinsella ...also, the government tactic of finding ways to bypass the HSE - it's a subtle war, really - has done untold damage IMO.

The Irish health service!!! “@stephenkinsella: What's the worst thing, in your opinion, about the Irish Health Service?”

@stephenkinsella You're setting up a joke aren't you?

@stephenkinsella the lack of agency of frontline staff.

@stephenkinsella the fact that it will be significantly worse in 12 months time!


@stephenkinsella Inertia. Everyone knows it could be better but nobody has any will on the inside to change it. Always someone else's fault.

@stephenkinsella The worst thing about the health service is the deconstruction of public health care in favour of private care.

@stephenkinsella The waste is the worst thing about the health service. The extra-ordinary levels of waste.

@stephenkinsella 2 tier n just saying in class is it the fault of @CardinalBrady old chum McQuaid styming mother n child


@stephenkinsella. The H.S.E.

@stephenkinsella that its so dysfunctional there is no fix. Start again is only solution

@stephenkinsella no one knows what the service actually is. It isn't coherent.

@stephenkinsella too much waste

Q: WHAT'S THE BEST THING ABOUT THE IRISH HEALTH SERVICE?

At first, no replies. Tried again, got these:

@stephenkinsella Best thing about Irish health system - the dirty hospitals are probably good building up your immune system over time.

@stephenkinsella How little I've had to deal with it ;)

@stephenkinsella can't answer that, still stinging from paying 77 euro (inc prescription costs) for doc visit yest.

@stephenkinsella Best thing about Irish health system - the dirty hospitals are probably good building up your immune system over time.

@stephenkinsella How little I've had to deal with it ;)

@stephenkinsella can't answer that, still stinging from paying 77 euro (inc prescription costs) for doc visit yest.

@stephenkinsella coming from the North still hard for me to fathom that you have to pay for doc


@stephenkinsella The coffee in the Hermitage medical centre.

@stephenkinsella Umm... that its influence is limited to a comparatively small country?

@stephenkinsella the staff without a doubt. Many of which work Overtime without pay.

@stephenkinsella domino scheme in NMH Holles st

@stephenkinsella The nurses.


@stephenkinsella Oncology care is simply miles ahead of what it was.


System. Bad

System. Bad People Within the System. Good.

SOME ‘FACTS’

SOME ‘FACTS’

Health expenditure has doubled since 2000, now €15bn

Next ten years will see no real increase in health expenditure.

3 Drivers: Evolution of national income, population structure, institutional specificities

Irish Government Spending and Revenues Source:Source: CSO, National Accounts Database. Note: The 2009 figure is a forecasted annual figure.

any measure, spending grew rapidly from 2000 onwards, the more so whensome of the measured output growth was borrowed from the future so tospeak, through building a large unsold stock of houses, retail and o!cespace, which will overhang the market for many years. Governmentspending relative to GNP was growing up to 2007, and even more so if theGNP growth rates and hence tax buoyancy from, say, 2002 onwards were intruth not as good as they looked, as we see in Figure 5.3. The dramatic

Understanding Ireland’s Economic Crisis

108

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40,000

50,000

60,000

70,000

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Year

2005 2006 2007 2008 2009

RevenuesSpending

! M

illio

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Figure 5.2: Irish Government Spending and Revenues

Source: CSO, National Accounts Database.Note: The 2009 figure is a forecasted annual figure.

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06_IEC-05 17/09/2010 07:20 Page 108

Basic Budget Deficit is crippling.

IRELAND’S FISCAL PROBLEM

0

12.5

25.0

37.5

50.0

Finlan

d 91

Norway

91

Swed

en 91

Turke

y 00

Japan

97

Korea 97

Malaysi

a 91

Thailan

d 97

Uruguay

02

Irelan

d 08

Fiscal Costs of Banking Crises, % GDP Anglo

10%3%

3%4%

15%

27%

38%

Social WelfareHealthEducationJusticeAgricultureEnterpriseOther

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!THE!SUSTAINABILITY!OF!IRISH!HEALTH!EXPENDITURE! 99

5.3.3!Drivers!of!Irish!Public!Health!Expenditure!As!discussed!in!Section!5.2.2,!empirical!analyses!of!the!determinants!expenditure! growth! over! time! in! developed! countries! tend! to! focuimpact!of!national! income,!population!growth! (and!composition)!anExamining! trends! in! Irish! public! health! expenditure,! population!composition,!national!income!and!prices!reveals!that!the!same!correlalargely!supported!by!Irish!experience!over!the!period!2000"2009!(see!FWhile! the! size!of! the!population! increased!by! 17.7!per! cent!over! th2000"2009,! the! share! of! the!population! aged! over! 65! years!declinedover!the!period.!The!growth!in!national!income!was!m

of!health!s! on! the!d!prices.!size! and!tions!are!igure!1).!e!period!! slightly!

uch!more!substantial,!as!

Figure!1:!Trends!in!Public!Health!Expenditure,!Population!Size,!Population!Composition,!National!Income!and!Prices,!2000"2009!(2000=1)!

was!the!change!in!both!the!level!of!overall!and!health!prices.!!

1.4

1.6

1.8

2.0

2.2

2.4

2.6

2.8

2000

=1.0

Public Health Expenditure

Population (Total)

Population (65+)

National Income (GNI)

CPI - All Items

1.2

1.02000 2001 2002 2003 2004 2005 2006 2007 2008 2009

CPI - Health

Notes:!Calculations! for!Public!Health!Expenditure! (PHE)! and!GNI! are!based!on! the!nominal!

.,!2010b.!,!and!CSO!

!over!the!

period!2000"2009!(health!prices! increased!by!64.0!per!cent!over!the!period,!in!comparison!with! 23.7! per! cent! for! ‘all! items’).23! Looking! in!more! detail! at!

! to! 2010!(June),!by! far! the! largest! increases!were!observed! for! the!categories! ‘hospital!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

figures.!2009!figures!for!GNI!are!not!yet!available!from!the!CSO;!based!on!Barrett!et!alSources:!Calculated!from!DoHC,!2009;!Barrett!et!al.,!2010b!for!PHE!and!GNI!figuresDatabase!Direct!for!population!and!CPI!figures!(www.cso.ie/px).!!

Looking!in!more!detail!at!Irish!health!prices,!of!the!12!CPI!group!headingsof!expenditure,! ‘health’!recorded!the!second!highest!rate!of! increase!

consumer! prices!within! the! ‘health’! heading! over! the! period! 2000

!23!The!fastest!rate!of! increase!was!observed!for! ‘education’!prices,!which!increased!by!86.4!per!cent!between!2000!and!2009.!

!

Trends in Public Health Expenditure, Population Size, Population Composition, National Income and Prices, 2000 2009 (2000=1), Brick et al, 2010: 99.


Figure! 3:!Harmonised! Index! of! Consumer! Prices! (All! Items! and!Health),!Selected!OECD!Countries,!2000"2009!

1.1

1.2

1.3

1.4

1.5

1.6

1.7

1.8

2000

=1.0

All Items Germany

All Items Ireland

All Items Netherlands

All Items Sweden

All Items UK

All Items USA

Health Germany

Health Ireland

Health Netherlands

Health Sweden

Health UK

1.02000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Health USA

nual!averages.!The!Harmonised!Index!of!Consumer!Prices!(HICP)!is!

!index!of!inflation!across!the!Euro!Area!of!the!EU.!In!contrast!to!!excludes!the!cost!of!owner"occupied!housing.!

nents! of!ceuticals!In!terms!!Medical!igh!Tech!

ave! experienced! substantial! increases! in!e!period!

!DP!

mmunity!pharmacists!amounted!to!#2.1!billion,!an!increase!of!181.0!per!cent!in!real!terms!

al! public!ceuticals!

Notes:!All!figures!refer!to!anan!internationally!comparablethe!Irish!CPI,!itSource:!Eurostat!(www.eurostat.eu)!

5.4.1!Overview!s!discussed! in! Section! 5.3.2,! one! of! the! fastest!growing! compoIrish!public!health!expenditure!is!public!expenditure!on!pharma

and!payments!to!pharmacists!(which!are!administered!by!the!PCRS).!of! total!PCRS!expenditure,! the!four!biggest!schemes!are! the!GeneralService!(GMS),!Drugs!Payment!(DP),!Long!Term!Illness!(LTI)!and!HDrugs! (HTD)! schemes.24! All! hexpenditure!on!pharmaceuticals!and!payments!to!pharmacists!over!th2000"2009.!At!present,!over!two"thirds!of!the!population!avail!of!the!GMS,and!LTI!schemes!(Bennett!et!al.,!2009).25!

In!2009,!public!expenditure!on!pharmaceuticals!and!payments!to!co

since! 2000! (see! Table! 7).! In! 2000,! approximately! 14.1! per! cent! of! tothealth!expenditure!was!accounted!for!by!public!expenditure!on!pharma

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!24!Non"GMS!drugs!schemes!are!commonly!referred!to!as!the!‘community!drugs!schem25!All! residents! of! Ireland!who! are! not! eligible! for! the!GMS! Scheme! are! eligible!Scheme;!however,!not!all!have!applied!for!DP!Scheme!cards.!While!those!eligible

es’!(CDS).!for! the!DP!

!for!the!GMS,!LTI!and!HTD!schemes! receive!all!prescription!medicines! free!of!charge,! the! remainder!of! the!population! (who!are!eligible! for! the!DP!Scheme)! receive! free!prescription!medicines!above!a!monthly!threshold!of!#120!per!family.!At!present,!approximately!30!per!cent!of!the!population!are!eligible!for!the!GMS!Scheme,!with!the!remainder!eligible!for!the!DP!Scheme.!In!2009,!64,472!and!54,466!individuals!availed!of!the!LTI!and!HTD!schemes!respectively!(Brick!et!al.,!2010b).!

c!5.4!PubliExpenditure!on A!!Pharmaceuticals!and!Payments!to!Pharmacists!

!

Price of medical care internationally. Harmonised Index of Consumer Prices (All Items and Health), Selected OECD Countries, 2000-2009. (Brick et al, 2010:101)


Figure! 3:!Harmonised! Index! of! Consumer! Prices! (All! Items! and!Health),!Selected!OECD!Countries,!2000"2009!

1.1

1.2

1.3

1.4

1.5

1.6

1.7

1.8

2000

=1.0

All Items Germany

All Items Ireland

All Items Netherlands

All Items Sweden

All Items UK

All Items USA

Health Germany

Health Ireland

Health Netherlands

Health Sweden

Health UK

1.02000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Health USA

nual!averages.!The!Harmonised!Index!of!Consumer!Prices!(HICP)!is!

!index!of!inflation!across!the!Euro!Area!of!the!EU.!In!contrast!to!!excludes!the!cost!of!owner"occupied!housing.!

nents! of!ceuticals!In!terms!!Medical!igh!Tech!

ave! experienced! substantial! increases! in!e!period!

!DP!

mmunity!pharmacists!amounted!to!#2.1!billion,!an!increase!of!181.0!per!cent!in!real!terms!

al! public!ceuticals!

Notes:!All!figures!refer!to!anan!internationally!comparablethe!Irish!CPI,!itSource:!Eurostat!(www.eurostat.eu)!

5.4.1!Overview!s!discussed! in! Section! 5.3.2,! one! of! the! fastest!growing! compoIrish!public!health!expenditure!is!public!expenditure!on!pharma

and!payments!to!pharmacists!(which!are!administered!by!the!PCRS).!of! total!PCRS!expenditure,! the!four!biggest!schemes!are! the!GeneralService!(GMS),!Drugs!Payment!(DP),!Long!Term!Illness!(LTI)!and!HDrugs! (HTD)! schemes.24! All! hexpenditure!on!pharmaceuticals!and!payments!to!pharmacists!over!th2000"2009.!At!present,!over!two"thirds!of!the!population!avail!of!the!GMS,and!LTI!schemes!(Bennett!et!al.,!2009).25!

In!2009,!public!expenditure!on!pharmaceuticals!and!payments!to!co

since! 2000! (see! Table! 7).! In! 2000,! approximately! 14.1! per! cent! of! tothealth!expenditure!was!accounted!for!by!public!expenditure!on!pharma

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!24!Non"GMS!drugs!schemes!are!commonly!referred!to!as!the!‘community!drugs!schem25!All! residents! of! Ireland!who! are! not! eligible! for! the!GMS! Scheme! are! eligible!Scheme;!however,!not!all!have!applied!for!DP!Scheme!cards.!While!those!eligible

es’!(CDS).!for! the!DP!

!for!the!GMS,!LTI!and!HTD!schemes! receive!all!prescription!medicines! free!of!charge,! the! remainder!of! the!population! (who!are!eligible! for! the!DP!Scheme)! receive! free!prescription!medicines!above!a!monthly!threshold!of!#120!per!family.!At!present,!approximately!30!per!cent!of!the!population!are!eligible!for!the!GMS!Scheme,!with!the!remainder!eligible!for!the!DP!Scheme.!In!2009,!64,472!and!54,466!individuals!availed!of!the!LTI!and!HTD!schemes!respectively!(Brick!et!al.,!2010b).!

c!5.4!PubliExpenditure!on A!!Pharmaceuticals!and!Payments!to!Pharmacists!

!

Price of medical care internationally. Harmonised Index of Consumer Prices (All Items and Health), Selected OECD Countries, 2000-2009. (Brick et al, 2010:101)

PROBLEMS WITH THESE ‘FACTS’

• Short time span. Over 50 years looks more like ‘catch up’ than ‘ramp up’. 60 days of eating, look at last 5 days.

• Concealing ‘social expenditure’ within ‘health expenditure’ (Wren, 2003)

• Disproportionate increases in Pay rather than Services Provision.

• A more complicated story.

HISTORY

1840s

1840s

Rudiments

1840s 1947

Rudiments

1840s 1947

Health actRudiments

1840s 1947

Health act

1980

Rudiments

1840s 1947

Health act

1980

Cut backs

Rudiments

1840s 20051947

Health act

1980

Cut backs

Rudiments

1840s 20051947

Health act

1980

Cut backs

HSERudiments

1840S

• < 1840s, Religious Institutions.

• Piecemeal evolution that ‘defies rational analysis” Wren (2003)

• Victorian hierarchies by 1900 within hospitals.

• Most of this persists today. (House ‘Officer’, etc)

• No ‘rational planning’, an evolution with 4 critical phases

1940S

• 1944 Dr FC Ward given a health ‘portfolio’.

• Initial remit: Improve medical inspection in schools, limit infectious diseases, free medical services for mothers, children < 16.

• Huge resistance from Church, IMO, Doctors, because of fees (Lee, 1989: 314-319)

1980S

• Savage cuts.

• 1983-1989, 22% of all beds lost. System starved of funds, investment, more importantly, over investment.

2000S

• HSE installed c. 2005.

• Huge changes in nomenclature, little in operational detail

• Changes in services now.

• “Like turning a ship”, except it isn’t. Health system is a complex system.

COMPLEX SYSTEMS

Many heterogenous parts

decentralised information & interaction

‘emergent’ properties: ant hills from individual ant behaviour.

Health care system is emergent~Gawande

Implication: you can’t predict where it will go with any accuracy.

Task 1: Represent Health Care system as a graph.

bedded within the Code that is not constrained by this

hierarchy.

Based on the characterization above, we can formulate

a mathematical representation of the Code as a graph G =

(V,E) with an associated “text” function T (v). V is the

set of vertices composed of all titles, subtitles, chapters,

subchapters, parts, subparts, sections, subsections, para-

graphs, subparagraphs, clauses, and subclauses. These

vertices can also be divided into two subsets: (1) vertices

that do contain text, written V T , and (2) vertices that do

not contain text, written V N . For vertices v ∈ V T that do

contain text, the associated “text” function T (v) returns

an ordered tuple containing the tokens within the text of

vertex v. For vertices v ∈ V N that do not contain text,

T (v) = ∅. The set of edges E can likewise be divided

into two subsets: (1) edges that encode the hierarchical

organization of the Code, written EH , and (2) edges that

record the citation network within the Code, written EC .

For convenience, we can then write the edge-induced sub-

graphs GH and GC that represent the hierarchical network

and citation network of the Code respectively.

For the remainder of this study, we fold the subtree

under each section vertex back into its respective section

vertex. For example, the text and citations from 26 U.S.C.

§501(c)(3) are merged up into 26 U.S.C. §501. While this

choice trades off some amount of detail in order to compare

the properties of T (v) across snapshots, we believe there

are several compelling justifications supporting this choice.

By focusing on sections, we ensure that all leaf vertices of

the hierarchy are of the same type. This makes a number of

network calculations much simpler and easier to interpret

than otherwise. Furthermore, unlike other vertices in V T ,

sections are the only type of vertex that is guaranteed to

contain complete grammatical units. This makes section

vertices the natural unit of analysis for any statements

regarding the language within the Code.

Though our attention throughout the remainder of the

paper is on the Code as a mathematical object, it is worth-

while to note that there are many important objects that

exhibit characteristics which are qualitatively similar to

the Code. For example, Internet web pages are hierar-

chically structured by IANA country code, domain, sub-

domain, and directory structures. These web pages also

contain large amounts of language and explicit interdepen-

dence in the form of hyperlinks. Therefore, the analysis

carried out in this paper could also be applied to web pages

on the Internet or any similar document. In summary, our

representation of the Code can therefore be more gener-

ally described as a formalization of a document with hi-

erarchical structure, explicit interdependence, and a

significant amount of language.

2. Measuring the Code

We can measure aspects of this representation of the

Code by constructing it from empirical data. To do so, we

have obtained XML snapshots of the Code at three points

in time: October 2008, November 2009, and March 2010.

This data was provided by the Cornell Legal Information

Institute ([3]). It is important to understand that the rate

of legislation and treaty-making exceeds the LRC’s rate of

codification. Furthermore, the LRC codification schedule

is based on titles, not on the chronology of the Statues atLarge. As a result, we cannot make compare the rate of

growth of different sections or titles of the Code with this

data. We can, however, make statements with respect to

aggregate changes in the Code.

(a) GH

(b) G

Figure 1: Network Visualization of the Code, Oct. 2008. Top: Hi-erarchical network, Reingold-Tilford circular layout ([10]). Bottom:Hierarchical network with citation network overlay in red.

Figure 1 offers two visualizations of the snapshot of the

Code as of October 2008. In panel (a), the hierarchical net-

work GH is shown branching out from the rooting node.

In panel (b), the section-to-section citation network is im-

posed in red onto the hierarchical network in (a). Note

2

ORGANISATION OF CAS

• To ‘solve’ health care problems, understand evolution of health service, essentially random. No plan.

• Evolved to solve some problems: deep & sequential, hence hierarchy.

• Culture matters, current state of affairs matters.

• Make decisions as close to information points as possible. Leave the rest alone. Don’t try for efficiency, not 1st objective.

POLICY IMPLICATIONS

A high-efficiency system performing large-scale repetitive tasks such as screening tests, inoculations, and generic health care, and a high-

complexity system treating complex medical problems of

individual patients locally.

TASK 2: UNIT COSTING

• Maximum information on service delivery at point of production

• Rely on team closest to treatment to decide allocation

• Bound expenditure at -5% each year per department

• Introduce accrual accountancy.

• Unit costs represent initial conditions of a very complicated dynamical system.

Microcosting of ELBW Infants(Kinsella, Philip,

McElligott 2008)

Microcosting of Radiology Units(Kinsella, et al,

2009, Kinsella & Young, 2010)

Microcosting of pediatric

Diabetes care(Ongoing w/

Prof. C’O’Gorman,

Prof. C. Dunne, Dr A. Macken)

Screening Dementia/Depression(Trepel et al,

2010)


2010)

Market-Based Reforms in the Health Sector

(Gerald O’Nolan, Eoin

Reeves)


2010)

Costing E-Healthinterventions(Lisa Hickey)

Market-Based Reforms in the Health Sector

(Gerald O’Nolan, Eoin

Reeves)

2 EXAMPLES.

<1>

BACKGROUND

1 Patient

Birth at 24 weeks: the marginal case

Many procedures required to keep patient alive

212 days in hospital

DATA

DATA176 variables over 212 days

DATA176 variables over 212 days 17 different antimicrobials,

DATA176 variables over 212 days 17 different antimicrobials, 479 ‘antibiotic days’

DATA176 variables over 212 days 17 different antimicrobials, 479 ‘antibiotic days’ 369 ‘diuretic-days’

DATA176 variables over 212 days 17 different antimicrobials, 479 ‘antibiotic days’ 369 ‘diuretic-days’ 95 ventilation days

DATA176 variables over 212 days 17 different antimicrobials, 479 ‘antibiotic days’ 369 ‘diuretic-days’ 95 ventilation days 86 transfusions

DATA176 variables over 212 days 17 different antimicrobials, 479 ‘antibiotic days’ 369 ‘diuretic-days’ 95 ventilation days 86 transfusions 83 radiological procedures including

DATA176 variables over 212 days 17 different antimicrobials, 479 ‘antibiotic days’ 369 ‘diuretic-days’ 95 ventilation days 86 transfusions 83 radiological procedures including 47 X-rays, 1 MRI, 35 ultrasound scans

DATA176 variables over 212 days 17 different antimicrobials, 479 ‘antibiotic days’ 369 ‘diuretic-days’ 95 ventilation days 86 transfusions 83 radiological procedures including 47 X-rays, 1 MRI, 35 ultrasound scans 940 laboratory investigations

DATA176 variables over 212 days 17 different antimicrobials, 479 ‘antibiotic days’ 369 ‘diuretic-days’ 95 ventilation days 86 transfusions 83 radiological procedures including 47 X-rays, 1 MRI, 35 ultrasound scans 940 laboratory investigations 2 x National Neonatal Transport Transfer

DATA176 variables over 212 days 17 different antimicrobials, 479 ‘antibiotic days’ 369 ‘diuretic-days’ 95 ventilation days 86 transfusions 83 radiological procedures including 47 X-rays, 1 MRI, 35 ultrasound scans 940 laboratory investigations 2 x National Neonatal Transport Transfer + Family’s Time, Equipment Maintenance, Refurbishment,

and more

METHOD

Assigned unit costs to chart variables.

Calculated Fixed, Variable, Total and Marginal Costs daily as

TC: Total Cost

Q: Extra day of life

MCt =∆TC

∆Q

Day 19: Fungal Sepsis, Transfer to Crumlin

Day 202:RSV Vaccination

COST REDUCTION AS WE APPROACH DISCHARGE

</1>

<2>

RSV BRONCHIOLITIS IN THE MID WEST

Commonest resp. tract infection in infancy


Majority of admissions are for supportive measures + observation



Prophylaxis options are RSV IVIG or palivizumab



Prophylaxis options are RSV IVIG or palivizumab

Costly method of reducing admissions to paediatric wards

Retrospective HIPE-data analysis from October 1999- Jan 2007

Data cleaned, analysed, included

Born in Mid-Western Regional Maternity Hosp

RSV +

Age <1 year at start of relevant bronchiolitis season

Cost calculated at bed occupancy rates

Number of NPA sent in each year by gestational age at birth

Opportunity Cost = (No. of babies in group not admitted * cost for an average stay for

that group)

less

(cost of prophylaxis * no. of babies)

less

(cost of babies admitted)

The total cost of RSV positive admissions during the period was €1,283,568.96, occupying 1276.38 bed days

DISTRIBUTION OF COST

Seasonal distribution of admissions and variation in length of stay

RSV admissions are increasing

Prophylaxis is having a positive effect on on admissions in premature babies but at high financial cost

Widening our criteria for Palivizumab will have enormous financial implications

</2>

RECOMMENDATIONS

RECAP

DISCUSS1. Break up HSE2. Rebuild system around 2 pillars1. High volume centralised system2. Low volume decentralised system3. Build each service around unit costs.4. Target each budget for -5% budgets year on year.

REFERENCES• Brick, A, Nolan, A., O’Reilly, J. and Smith, S. Resource Allocation,

Financing and Sustainability in Health Care VolumeII. Evidence for the Expert Group on Resource Allocation and Financing in the Health Sector. Dublin, Department of Health and Children and Economic and Social Research Institute, 2010

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• Y. Bar-Yam, Improving the Effectiveness of Health Care and Public Health: A Multi-Scale Complex Systems Analysis, American Journal of Public Health. 96, 459-466 (2006)

http://www.necsi.edu/research/management/health/AJPH/index.html




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