A mixed-methods evaluation of novel services for vulnerable patient groups in Ireland

Introduction: Rising healthcare costs present a challenge to healthcare 
\nsystems around the world. In Ireland, healthcare spending accounts for greater 
\nthan a quarter of government expenditure. Cancer patients and older persons 
\nare two patient population groups that account for a large portion of healthcare 
\nutilisation and both groups are continuously increasing in number. Safe, cost-
\neffective innovations are needed to provide care for these population groups 
\nwhile maintaining an adequate level of spending. This thesis sought to 
\nevaluate novel interventions that target cancer patients and older persons in 
\nIreland, assessing both cost and quality of the interventions.
\n
\nMethods: This thesis examined the cost and quality of the introduction of the 
\nnovel services in Cancer and Older Person services i.e. Community Oncology 
\nNursing Programme in the West of Ireland, the monitoring of oral anti-cancer 
\ntherapies (OATs) nationally and the Optimising thERapy to prevent avoidable 
\nhospital Admissions in Multi-morbid older people (OPERAM) trial in Cork. 
\nThese interventions were chosen as examples of recent innovations in the 
\ncare of vulnerable, costly patient groups. Diverse local, regional and national 
\nIrish healthcare settings were evaluated, using a mix of economic evaluation 
\nand qualitative principles, as part of this thesis. Methodologies such as 
\nliterature reviews, economic evaluations (cost-effectiveness analysis and cost 
\ncomparison analysis), and qualitative analysis (using the thematic analysis) 
\nhelped provide evidence and inform the recommendations.
\n
\nResults: The full service pathway of cancer care provision in the hospital and 
\ncommunity settings were mapped at a high-level. This was the first step of a Time-Driven Activity-Based Costing (TDABC) model of cost evaluation. Both 
\ninternal and external evaluation of the service was carried out. Inefficiencies 
\nwere noted in the process flow, although these were unable to be addressed 
\ndue to financial and time restraints.
\nThe cost of providing cancer care in the community, that being in primary care 
\ncentres or the patient’s own home, were compared to providing the same care 
\nin an oncology day ward. Both the Irish health payer and societal perspectives 
\nwere evaluated. From the healthcare provider perspective, the day-ward was 
\na significantly cheaper option by an average of €17.13 per patient (95% CI 
\n€13.72 - €20.54, p<0.001). From the societal perspective, the community 
\noption was cheaper by an average of €2.77 per patient (95% CI -€3.02 –
\n€8.55), although this was statistically a non-significant finding. Sensitivity 
\nanalyses indicate that the community service model may be significantly 
\ncheaper from the societal perspective.
\nSemi-structured interviews with patients, community and hospital nurses 
\ninvolved in cancer care in the West of Ireland were analysed using thematic 
\nanalysis. Four themes of improved patient experience, nurse-patient 
\nrelationship, the importance of location and roadblocks to further 
\nimplementation of the programme emerged. All interviewees expressed their 
\nbelief that the introduction of the programme was a positive for patients.
\nThe cost and qualitative impact of the monitoring of OATs was assessed. The 
\nmedian consultation time was 33 minutes, costing an average of €22.10 per 
\nconsultation, using Clinical Nurse Specialist salary figures and €26.51 per 
\nconsultation, using Advanced Nurse Practitioner salary figures. The associated patient cost was €14.06 using the Human Capital method to 
\ncalculate costs incurred from lost work productivity. Themes of the effect of 
\nCovid-19 on the service, expanding and complicated care package 
\nrequirements, the need for dedicated oral clinics and the future of the service 
\nemerged from the interview data. 
\nCare of the older person in Ireland also equates to a significant cost to the Irish 
\nHealthcare system. A clinical decision support system, used to apply the 
\nSTOPP/START version 2 criteria to older persons in hospital across Europe, 
\nwas assessed for cost-effectiveness. The data within this thesis analysed the 
\ncost-effectiveness and costs of the Irish data using simple difference and 
\nSeemingly Unrelated REGression (SUREG) models. The intervention showed 
\nno significant improvement in quality of life. By simple difference, the average 
\ndifference in total costs was €757 per participant in favour of the intervention 
\ngroup, this was not a significant finding (p=0.790). In the SUREG model the 
\nintervention showed a cost saving of €1477 per participant, not a significant 
\ndifference. (p=0.341).
\n
\nConclusion: The novel findings of this thesis offer insight into the 
\neffectiveness of the services and the potential for alternative methods of care 
\ndelivery to be incorporated into national policy. The Irish healthcare system is 
\nin the midst of a reformation as part of the Sláintecare strategy, and the 
\nfindings of this thesis are supportive of its drive towards a shift to primary care. 
\nThe findings of this thesis provide specific information for policy makers on the 
\nexamined interventions, and provides a roadmap for future research of novel 
\nevaluations targeting the vulnerable population groups assessed here.

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