Health Minister Jonathan Coleman says Health Benefits Limited (HBL) will be wound up and a new DHB owned company will implement the shared services programme from 1 July 2015.

“It is important to maintain momentum and progress the DHB shared services programmes to ensure substantial savings are freed up from the back office and reinvested into frontline health services,” says Dr Coleman.

“Cabinet has today agreed to the establishment of NZ Health Partnerships Limited which will be equally owned by all DHBs and lead the implementation of the shared services business cases.”

In November 2014, Dr Coleman asked DHBs to put forward a proposal to implement the shared service business cases for finance and procurement, laundry, national IT infrastructure, and food services.  

“HBL led this work through the development phase, and now that we are in the implementation phase, the responsibility best sits with DHBs,” says Dr Coleman.

“The HBL Transition Interim Governance Group has worked through the next steps, including a due diligence process, and all DHBs have approved the final proposal.”

HBL will be wound up by 30 June, and the new company, NZ Health Partnerships Limited, will come into effect from 1 July with transitional governance and management arrangements in place.

HBL and DHBs have achieved over $300 million in savings since HBL was established in July 2010.

This is an economic evaluation from the perspective of the payer: the Ministry of Health and Long-Term Care of Ontario. All eConsults submitted during April 1, 2011 to March 31, 2014 were included. The authors attributed cost savings only to those cases where an eConsult led to the avoidance of a face-to-face specialist visit.

A total of 2606 eConsults directed to 27 different speciality groups were included. In 40.3% (n=1051) of cases processed, a face-to-face specialist visit was originally planned but avoided as a result of eConsult, while 29% led to a referral. The estimated cost per eConsult for Years 1, 2, and 3 were $131.05, $10.34, and $6.45 respectively. Results from a sensitivity analysis project that the eConsult service will break even once it reaches 7818 eConsults.

The authors note that this is one of the first studies to examine costs across a multispecialty eConsult service. They saw a marked decrease in the cost per eConsult over each annual period. They go on to say that future research is needed to identify and examine similar outcomes that may lead to cost savings.

This is an open access document and can be downloaded in free full text at:  http://dx.doi.org/10.3233/978-1-61499-505-0-67

Liddy, C., et al. (2015). What are the costs of improving access to specialists through eConsultation? The Champlain BASE Experience. In: Vol. 209: Global Telehealth 2015: Integrating Technology and Information for Better Healthcare.

A simple solution to a costly problem has seen a Hauraki health provider reduce the number of people missing specialist hospital appointments by about 49 per cent – saving the public hundreds of thousands of dollars.

Te Korowai Hauora o Hauraki has reduced its patient ‘did not attend’ (DNA) rates from 25.6 per cent in 2005 to 11.82 per cent last year.

Te Korowai kaiawhaina services co-ordinator Heather Makiri-Wi spends up to two hours a day phoning and texting up to 30 patients in an effort to ensure they make appointments.

She said patients do not turn up for several reasons such as lack of transport, fear or sometimes they just forget.

Makiri-Wi said a common problem is that many patients cannot afford to use their phones to cancel an appointment.

“If there was an 0800 number it would help,” she said.

The DNA phone and text monitoring programme was initiated by the hospital in 2005 with the DNA rate dropping from 25.6 per cent to 16 per cent the following year.

The programme ceased after a new computer system was installed at Thames Hospital but it was reactivated in 2011.

The efforts since then have led to the lowest recorded DNA rate.

Te Korowai general manger of operations Gwendol Welburn said the results show how important it is to follow up with patients.

“There is definitely a need for someone like Heather to do this,” she said.

Welburn said many people do not realise it costs the hospital about $375 per patient, $600,000 per year when they miss a scheduled appointment but more so it also delays treatment for someone else.

Outpatients manager Rodger Clark said the Ministry of Health expects everyone will receive a first specialist appointment within four months of being placed on the waiting list.

“It is frustrating when people do not attend appoints because that appointment could have been offered to someone else.”

He said paediatrics was one of the worst for DNAs with 45 per cent of December bookings unattended.

Thames Hospital and community service manager Jacquie Mitchell said people don’t realise the implications their actions have.

“We wait for a person to show up, someone we have invested a whole lot of time in and [then when they don’t] other people get frustrated because they miss out on an appointment or surgery.

“It could be your family or neighbour who misses out on an appointment,” she said.

However Mitchell is delighted at the success of Te Korowai’s monitoring programme and thanked all the staff for their efforts.

The average rate for DNAs in Thames is 9 per cent, about 1600 people, compared to 8 per cent across the Waikato DHB area.

Further work is being done to reduce those figures, including a weekend monitoring system.

A total of 53 studies were included (including 19 systematic reviews and 34 primary studies). Although the overall evidence base was varied and frequently lacked a robust study design, the authors identified a range of interventions that showed potential to reduce length of stay. These were multidisciplinary team working, for example some forms of organised stroke care; improved discharge planning; early supported discharge programmes; and care pathways. Nursing-led inpatient units were associated with improved outcomes but, if anything, increased length of stay. Factors influencing the impact of interventions on length of stay included contextual factors and the population targeted. The evidence was mixed with regard to the extent to which interventions seeking to reduce length of stay were associated with cost savings.

The authors discuss the implications of these findings. 

This is an open access report and is available to download and read in free full text at:  http://dx.doi.org/10.3310/hsdr02520

Miani C, Ball S, Pitchforth E, Exley J, King S, Roland M, et al. (2014). Organisational interventions to reduce length of stay in hospital: a rapid evidence assessment. Health Services and Delivery Research, 2(52).

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1308/003588414X13946184903649 or contact your DHB library, or organisational or local library for assistance.

Chen, S., et al. (2015). A meta-analysis of fast track surgery for patients with gastric cancer undergoing gastrectomy. Annals of The Royal College of Surgeons of England, 97(1), 3-10.

A building management system upgrade is set to save Capital & Coast District Health Board (CCDHB) at least $300,000 on its yearly power bill.

The building management system (BMS) currently being upgraded is the combination of hardware and software that is responsible for maintaining air quality and temperature throughout the hospital.

Parts of Wellington Hospital’s existing BMS are over 20 years old. Recent independent audits have identified that many air handling systems for specialist areas such as surgical theatres and isolation rooms operate unnecessarily at full speed 24/7.

Facilities and engineering operations manager Leon Clews says that the functionality of a modern BMS will allow air quality and temperatures to be efficiently maintained with minimal energy usage.

“With the ability to tune air handlers to suit individual environments like theatres or meeting rooms, we expect to save at least $300,000 per year in gas and electricity costs,” he says.

The upgrade will also reduce the DHB’s carbon footprint by 983 tonnes of carbon dioxide (CO2) per year, which is equivalent to planting about 400 hectares of trees each year indefinitely.

It is also equivalent to avoiding burning a 270 tonne pile of coal, the weight of fifteen typical city buses. 

“This upgrade is an important step to for CCDHB to achieve the goals set by our Energy Efficiency statement of intent, which include reducing our energy usage by 40% by 2021,” Mr Clews says.

South Island DHBs have saved over $4million through initiatives in facilities and maintenance. By working collaboratively through the South Island Alliance's Support Services group, DHBs' facilities and maintenance teams have implemented new technologies and taken advantage of bulk buying contracts to reduce facilities and maintenance costs by $4.32 million.

Initiatives for savings included things like installing new more efficient boilers and light bulbs, renegotiating electricity contracts and collectively using one architectural and drafting contract for building works.

Chair of the Support Services group that undertook the work and Southern DHB Building and Property Manager Warren Taylor said the ability to share ideas was key to the successful cost reductions. "By being able to work alongside counterparts around the South Island we could each clearly see areas where we could find efficiencies and work together to negotiate contracts."

"To save over $4million was a huge achievement and that money can now be reinvested in patient care and in further building and facilities initiatives. We always have to make careful decisions about how we prioritise maintenance and facilities upgrades, but by working together through the Alliance, we have been able to work more efficiently and stretch the health dollar further than before."

Case Study: Nelson Marlborough DHB shift to energy efficient lights
One idea that has come into fruition has been Nelson Hospitals replacement of fluorescent lights with energy efficient LED lights. This is a huge job, with around 3600 lights needing to be replaced. However, the time and cost involved in the upgrading the old lights are well worth it when balanced against the benefits:

• Using low energy LED lights will reduce the hospital's energy consumption by 10 percent
• Lighting quality is better for staff and patients
• LED lights are non-toxic, meaning less dangerous waste going into landfills
• LED lights also emit less heat, meaning a reduction in the level of air conditioning required

By being able to share ideas and develop best practise through the Alliance, South Island DHBs have been able to implement a whole range of initiatives like this one in Nelson Hospital that are improving efficiency in facilities and maintenance.

Eight years ago Waikato District Health Board (DHB) paid more than $523,000 a year to advertise for staff. In the last financial year that figure had reduced by 82 per cent to $93,130, acting general manager Human Resources Greg Peploe told the board at its monthly meeting yesterday (26 November).

“The DHB continues to push for savings,” he said.

“Already this financial year the DHB comparable spend for recruitment advertising has reduced by a further $18,807.”

Of significance last month was the appointment of a general medicine physician to a role which had been advertised for nearly a year.

“The successful candidate is New Zealand trained, returning from working in the UK, to commence in February 2015.”

Waikato DHB does very little print advertising now “because it is not effective anymore.”

Instead it relies on its own website www.waikatodhb.health.nz/jobs where it sources 60 per cent of its successful candidates.

Four per cent come from Kiwihealthjobs which is New Zealand’s largest dedicated health job board owned by the 20 district health boards and NZ Blood Service.

Launched in 2011, it now regularly receives more than 40,000 visitors each month.

Recently it launched an advertising pilot for non-district health board organisations.

What started out as a relatively small site,has now become a leading brand for health sector opportunities.

“Six per cent of (our) successful candidates find out about the job through a friend or word of mouth,” said Mr Peploe.

“This is an important source for harder to reach candidates.”

All Waikato DHB positions are advertised on its website and feature on the DHB’s Facebook and Twitter feeds.

The report authors suggest that savings of nearly £2 billion can be made through better clinical practice, for example in the use of tests and medicines.

Among the report’s recommendations is a call for greater use of NICE’s ‘do not do’ database, which it describes as an “excellent resource” for doctors who want to question the value of particular clinical practices.

NICE’s ‘do not do’ database contains all the recommendations that NICE has made for clinical practices that should either be discontinued or not used routinely within the NHS.

To download the report, go to:  http://www.aomrc.org.uk/doc_download/9793-protecting-resources-promoting-value.html

To read a NICE news article about the report, go to:  https://www.nice.org.uk/news/article/cut-nhs-waste-through-nice%E2%80%99s-%E2%80%98do-not-do%E2%80%99-database

Health Minister Jonathan Coleman says the Government is considering options for moving to the implementation stage of the DHB shared services programme.

“Health Benefits Limited (HBL) has made good progress in developing savings plans for DHBs,” says Dr Coleman.

“These programmes will result in substantial savings being freed up from the back office and re-invested into frontline health services such as more operations, and better cancer treatment.”

The business cases on finance and procurement, laundry, national IT infrastructure, and food services have been developed.

“These cases now have to be implemented, and it is important to get this process right,” says Dr Coleman.

“The Government needs certainty on the investment costs and savings projections, and the path ahead. 

“DHBs need to be highly engaged around investment decisions and the Government is seeking their views on the best way to implement the business cases.”

HBL and DHBs have achieved over $300 million in savings since HBL was established in July 2010. DHBs are for example saving around $4 million a year after signing up to a collective banking arrangement.

Health Minister Jonathan Coleman says an additional 42,885 New Zealanders benefited from Pharmac’s decisions on funded medicines in 2013/14.

“Pharmac has a good track record on controlling pharmaceutical costs while increasing subsidised medicines and treatments for more New Zealanders,” says Dr Coleman.

“Its latest annual report for 2013/14 shows in the last year Pharmac funded 26 new medicines and widened access to a further 35 medicines. This has benefited thousands of New Zealanders.

“Last month Pharmac approved its largest single deal with Novartis and Biogen Idec which will see 10 new medicines funded, and either reduced prices or widened access to eight others. This includes better access to new multiple sclerosis medicines.

“In addition to funding new medicines, Pharmac achieved savings of $52.2 million which helped to make new investments possible.”

In 2013 Pharmac’s role was expanded to include the management of community medicines, pharmaceutical cancer treatments, the National Immunisation Schedule, management of all medicines used in DHB hospitals, and the national contracting of hospital medical devices.

“In its first year of managing hospital medicines and beginning national contracting for hospital medical devices, Pharmac achieved net annual savings to DHBs of $25.62 million,” says Dr Coleman.

Pharmac’s annual report for 2013/14 can be found at: www.pharmac.health.nz.

DHBs are expected to start making further savings in cardiac medical devices, after PHARMAC extended the range of products it already has under national contracts by beginning listing those used in cardiac procedures.

The 303 items now listed on the Pharmaceutical Schedule are the first in what is expected to be a large number of interventional cardiology medical devices available at national prices.

The agreement with Bio-Excel includes equipment such as stents and balloons and offers DHBs initial savings of about $150,000 from current national expenditure of about $1.2 million.

Following discussions with the Cardiac Society and a Registration of Interest process earlier this year, PHARMAC sought proposals from suppliers, and this is the first agreement reached with a supplier in the interventional cardiology category.     

Director of Operations, Sarah Fitt, says PHARMAC’s contracting in the medical device area is increasing quickly and highlights its drive to create value for DHBs.

“We’ve already put in place nine other national agreements across the categories of wound care, sutures and laparoscopic equipment, and this move into interventional cardiology devices means we are now able to offer DHBs over $2 million in savings if they take up these opportunities,” Sarah Fitt says.

“We’ve now got over 5000 medical devices under contract covering national expenditure of about $35 million and our activity in this space is increasing all the time. We’re looking to expand the number of contracts available in the current categories, while also seeking agreements with suppliers in other areas, such as devices used in trauma surgery.”

PHARMAC is currently consulting on a proposal to list a further 630 interventional cardiology devices supplied by Medtronic, offering potential savings of another $200,000 to DHBs.

PHARMAC is aiming to get nationally consistent lower prices, and reduce future pricing pressures, on items that many DHBs are already using.

"Analysis at a population level suggests if 10,000 individuals receive 12 weeks of specialist evidence-based care, the cost savings are likely to be A$9,238,800. Significant savings could be made by the adoption of evidence-based care such as that provided by the community and outpatient specialist wound clinics in this study".

To read the full abstract, and for information on how to access the full text, go to: http://search.informit.com.au/documentSummary;dn=668374495637499;res=IELHEA or contact your DHB library, or organisational or local library for assistance.

Graves, N; Finlayson, K; Gibb, M; O'Reilly, M and Edwards, H. (2014). Modelling the economic benefits of gold standard care for chronic wounds in a community setting. Wound Practice & Research: Journal of the Australian Wound Management Association, 22(3), 163-168.

Thirty four articles comprising 35 analyses met the inclusion criteria. Based on their analysis, the authors conclude that "the extent that HF-MPs reduce hospital readmissions appears to be associated with favorable cost outcomes. The current evidence does not provide a sufficient evidence base to explain what intervention or clinical attributes may influence the cost implications".

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1177/1474515114556031 or contact your DHB library, or organisational or local library for assistance.

Maru, S., et al. (2014). Systematic review of trial-based analyses reporting the economic impact of heart failure management programs compared with usual care. European Journal of Cardiovascular Nursing, 16 October [Epub before print]

Vascular surgeon Mr Kes Wicks says the new treatment, known as isolated pharmacomechanical thrombolysis, means patients avoid multiple trips to theatre and at least 72 hours spent lying on their front.

“Basically, we isolate the clot between two balloons and use a small wire to blend it up, then we suck it back out instead of waiting for it to dissolve on its own.”

The speed of the treatment also reduces the risk of post-thrombotic syndrome, which is the biggest cost associated with DVT.

To read the full media release from Capital and Coast District Health Board, go to: http://www.scoop.co.nz/stories/GE1410/S00132/the-right-blend-of-treatment-for-deep-vein-thrombosis.htm

The authors outline a Digital Health Selection Framework to guide patients, providers, and payers through the procurement of technology to help them achieve the Triple Aim.

To access this paper in full text, you need to be a registered member of IHI. Registration is free. To read the full abstract and for a link to the full text, go to: http://www.ihi.org/resources/Pages/Publications/AFrameworkforSelectingDigitalHealthTechnology.aspx

Ostrovsky A, Deen N, Simon A, Mate K. (2014). A framework for selecting digital health technology. IHI innovation report. Cambridge, MA: Institute for Healthcare Improvement; June.

Over 1200 US hospitals are currently participating in Keystone ICU. This paper examines the cost changes and cost-effectiveness of the Keystone ICU project from the perspective of the hospital, using a decision tree model to address the choice faced at an individual hospital about implementing the programme) and nationally representative data sources.

The authors found that, this programme, as it is currently implemented by hospitals on an increasingly large scale in the USA, likely reduces the economic costs of central line-associated bloodstream infections for US hospitals. Awareness among hospitals about the programme's benefits should enhance implementation. The programme's implementation has the potential to substantially reduce morbidity, mortality and economic costs associated with central line-associated bloodstream infections.

This is an open access article and can be read in full text at: http://dx.doi.org/10.1136/bmjopen-2014-006065

Herzer, K.R., et al. (2014). Cost-effectiveness of a quality improvement programme to reduce central line-associated bloodstream infections in intensive care units in the USA. BMJ Open, 4, e006065.

Value in Health is the official journal of the International Society for Pharmacoeconomics and Outcomes Research.

These case studies fall into the following areas:

• Reviewing care and medicines use in care homes
• Improving the design and delivery of ambulatory care
• Redesign of acute services and departments
• Delivering a more efficient and person-centred acute discharge process

To access the case studies, go to: http://www.health.org.uk/news-and-events/newsletter/eight-case-studies-that-show-you-can-improve-quality-while-also-saving-money/

The scan aimed to provide evidence on austerity and health care from a wider international perspective, focusing in particular on the following four questions:

1. What policy responses have health systems internationally taken in response to the financial crisis?
2. How effective have these measures been in achieving cost savings and efficiencies?
3. What impact have these measures had – desired or unintended – on the quality of care?
4. What can the UK NHS learn from experiences and evidence from elsewhere?

The project took a case study approach, gathering and analysing evidence for the following six countries: Canada, Denmark, Ireland, the Netherlands, Portugal and Spain.

To download and read the evidence scan in full text, go to: http://www.health.org.uk/publications/international-responses-to-austerity/

Ellins, J., et al. (2014). International responses to austerity. London: Health Foundation.

Knee and/or hip joint replacement surgical patients are hugely benefiting from receiving Tranexamic Acid injections before surgery at Palmerston North Hospital.

Patients are getting mobilised sooner, are spending less time in hospital, don’t need blood transfusions, and are showing reduced signs of swelling after leaving hospital, thanks to orthopaedic surgeons giving them the injections.

An initial trial of 15 knee or hip joint replacement surgery patients were given the injections to see if it would reduce blood loss, the need for blood transfusions, and the need for blood drains.

The trial by orthopaedic surgeons at Palmerston North Hospital has gone better than expected with huge benefits for patients, with reduced costs another unexpected but welcome benefit.

Surgeons wanted to know if the injections had:

• Reduced the need for blood transfusions
• Have patients mobilised earlier because of it
• Has it reduced the length of stay for patients
• Has it reduced cost with not having to administer blood transfusions, and
• Has it reduced cost with not using blood drains

Results have shown the average time it took a patient to mobilise has reduced from 22.83 hours to 18.7 hours.

The average length of stay for a patient has reduced from 3.7 days to 3.5 days.

Also there has been a noticeable reduction in swelling and bruising 10 to 14 days after surgery, especially for knee replacement patients.

All up the project has also produced an unexpected saving of about $200-$300 per patient not having blood transfusions, and blood drains, and only needing one to two tranexamic acid injections a patient depending on which procedure they have.

In this prospective observational study, the authors investigated the effects of displaying reference laboratory costs and turn-around times during computerised physician order entry (CPOE) on inpatient physician ordering behaviour at a tertiary care hospital.

After the intervention, the mean number of monthly physician orders per inpatient day at risk decreased by 26% with a decrease in mean cost per order. The authors conclude that "display of reference laboratory cost and turn-around time data during real-time ordering may result in significant decreases in ordering of reference laboratory tests with subsequent cost savings".

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1136/bmjqs-2014-003053 or contact your DHB library, or organisational or local library for assistance.

Fang, D.Z., et al. (2014). Cost and turn-around time display decreases inpatient ordering of reference laboratory tests: A time series. BMJ Quality & Safety, 23(12), 994-1000.

DHBs will save another $650,000 a year from lower priced wound care and surgery equipment through a new national PHARMAC agreement with a major medical device supplier.

From 1 September, DHBs can use a national contract to buy products from Covidien New Zealand Limited including wound dressings, casting bandages, medical tapes, surgical stitches (sutures) and items used in abdominal keyhole surgery.

The agreement follows others PHARMAC has reached with eight other suppliers of medical devices such as wound care, sutures and disposable laparoscopic equipment. Since February this year PHARMAC has listed almost 5000 individual medical device products on the Pharmaceutical Schedule.

So far, PHARMAC has achieved minimum national annual savings of almost $2 million for DHBs through its medical device procurement activity since the first listing earlier this year.

The new contract with Covidien covers products that account for DHB spending of about $4.6 million per year, with savings of over 14 percent.

Previously DHBs had to individually negotiate their own prices for these products and potentially ended up paying different prices for the same products.

PHARMAC is aiming to get nationally consistent lower prices, and reduce future pricing pressures, on items that many DHBs and primary care providers are already using.

Director of Operations Sarah Fitt says the deal is significant.

“Covidien is one of a number of major suppliers to DHBs and this agreement means all DHBs can get this equipment for the same price. Equal access across the country and transparent pricing is a key reason why PHARMAC is doing this work, but we also need to get savings for DHBs at the same time,” Sarah Fitt says.

“The contracts are also protection for DHBs against rising prices.”

“PHARMAC is now looking toward reaching agreements with suppliers of interventional cardiology equipment and orthopaedic implants and will be expanding into other categories of products over time.”

This national contracting activity is the first step towards PHARMAC assuming broader responsibility for hospital medical devices on behalf of DHBs– in the same way it manages new technology assessment, contracting and expenditure on hospital and community medicines, and vaccines.

Details about PHARMAC’s medical device activity and its work towards management, can be found on its website: www.pharmac.health.nz/medicines/hospital-devices/

The author also notes that "many small studies reported high satisfaction rates of these models among patients and health professionals including Indigenous populations. One single center study reports that it is safe to supervise chemotherapy delivery remotely and many studies report cost savings to the health systems". The author goes on to say that "future teleoncology models would need to include web-based models, mobile technologies and remote chemotherapy supervision models".

Available to read in full text at: http://onlinelibrary.wiley.com/doi/10.1111/ajco.12225/full

Sabesan, S. (2014), Medical models of teleoncology: Current status and future directions. Asia-Pacific Journal of Clinical Oncology, 10(3), 200-204.

In this rapid evidence synthesis, the authors assess the evidence on the impact of enhanced recovery programmes for patients undergoing elective surgery in acute hospital settings in the UK.

The authors modelled the cost-effectiveness of the Ottawa Model for Smoking Cessation (OMSC), an intervention that includes in-hospital counselling, pharmacotherapy and posthospital follow-up, compared to usual care among smokers hospitalised with acute myocardial infarction, unstable angina, heart failure, and chronic obstructive pulmonary disease.

They found that the "... estimated net economic benefits ranged from $640 million to $1.8 billion, with the corresponding net benefits per case averted ranging from $15,780 to $24,391. The per dollar rate of return on the CDC’s investments ranged from $3.88 to $23.85". 

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1377/hlthaff.2013.0865 or contact your DHB library, or organisational or local library for assistance.

Scott, R.D., et al. (2014). CDC central-line bloodstream infection prevention efforts produced net benefits of at least $640 million during 1990–2008. Health Affairs, 33(6), 1040-1047.

Six relevant economic evaluations were assessed (3 from North America and 3 studies from Europe). "All studies reported the use of home monitoring devices that measured and transmitted different physical indicators to nurses who provided personalised feedback to patients during weekdays. The six studies involved a total of 559 COPD patients of whom 281 were randomised to telehealth. The review demonstrated a potential for cost savings ... However, the quality of the economic evidence was poor ....[and] caution is advised for healthcare decision-makers seeking large-scale implementation of telehealth in routine clinical practice".

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1177/1357633X14533896 or contact your DHB library, or organisational or local library for assistance.

Udsen, F.W., et al. (2014). A systematic review of the cost and cost-effectiveness of telehealth for patients suffering from chronic obstructive pulmonary disease. Journal of Telemedicine and Telecare, 20(4), 212-220.

Changes to the Nelson Marlborough District Health Board (NMDHB) linen usage are giving patients a more comfortable stay while significantly reducing the cost of laundering. 

The adopted ‘love your linen’ initiative is being driven regionally by the South Island Alliance (SIA) as it seeks to improve patient quality and experience and increase efficiencies through improved hospital support services across all the DHBs, linen and laundry being one of them.

Sandy Russell, Chair of the SIA Laundry Work group and Manager of Hotel Services at NMDHB said the Alliance has completed extensive work around linen rationalisation and standardisation.

“These initiatives have been taken back and implemented within NMDHB, with a number of benefits both financial (reduced cost) and non-financial (reduced time and effort).”

 The average spend per admission highlights the cost benefits to NMDHB; a 26% reduction from $19.10 in 2011/12 to $15.11 for the first four months of 2013/14, which factors in a 1.5% increase in the price of linen due to increased power charges.

“The initiative not only brought cost savings to the DHB but has made beds more comfortable for patients and easier to make for assistants,” said Ms Russell.

“Our traditional flat sheets did not cover or tuck in our new beds, not only requiring the time to fit them properly, but creasing underneath and causing pressure points for less mobile patients,” she explained.

“We now have a fitted sheet with a softer more comfortable and cozy fabric that fits over the bed and remains more secure with less risk for pressure points and other related skin breaks. It also eliminates the need for an under blanket, which saves assistants time to make the beds, and reduces laundering costs and time, particularly as the old cell blankets took longer to dry using more power also.”

Ms Russell said it was a simple fit-for-purpose initiative, but one that was made much easier by being able to utilise a regional solution, where best practice guidelines, linen catalogue and support resources were available to all DHBs.

“In Nelson Marlborough our health care assistants, nurses and household staff have reported a reduction in the time taken to make and strip beds, resulting in greater efficiency and clinical time being released.”

 “Southern has also utilised new linen usage policy, reaping the rewards,” said Ms Russell.

 The SIA purpose of the best practice initiatives adopted by NMDHB and SDHB are to:

• drive standardisation for efficiency
• ensure linen is fit for purpose
• free up valuable storage space on wards
• free up nurse, health care assistant and household staff time
• reduce environmental impacts from laundering excess linen
• encourage sustainable linen use
• reduce costs.

PHARMAC has announced its intention to test out a contestable fund for high cost medicines for rare disorders, which could be seeking proposals from pharmaceutical companies by the end of 2014.

Promoting competition among suppliers could be the key to improving patients’ access to high cost medicines for rare disorders, says chief executive Steffan Crausaz.

The fund is a response to concerns about access to these medicines that PHARMAC has been hearing from patients through forums and consultations in recent months.

“We’ve listened closely to these views, and thought about them carefully. Our thinking leads us to the view that the core problem is a lack of competition,” says Steffan Crausaz.

“We know competition leads to lower prices, and that’s an area where PHARMAC has an established track record. Our activities in promoting competition enable New Zealand to achieve some of the lowest prices for medicines in the world.”

“We think that by promoting competition among suppliers, prices will reduce and as a result, patients will get funded access to them. Ultimately, that’s what this fund is about.”

“Pharmaceutical suppliers tell us one of their main motivators is providing patients with access to their products. That’s something we certainly want to see, and I hope the industry takes this opportunity to help us find a way to make these medicines more available to patients.”

Steffan Crausaz says the new approach is possible within PHARMAC’s current operating framework, and would still involve PHARMAC seeking to get the best health outcomes for patients from the available funding for pharmaceuticals.

“PHARMAC will continue to look for the best health outcomes for patients, and the best value investments. The approach we intend to use will be consistent with the PHARMAC model and, importantly, will still enable us to continue to fund other new medicines for conditions that aren’t rare.”

PHARMAC has published a discussion paper on its website and is inviting comments from the public and industry on the contestable fund. These comments would help iron out some of the detail of how the fund would operate.

Steffan Crausaz says up to $5 million per year may be available, through funding that has already been budgeted but not likely to be used for the $8 million exceptions policy. Because this funding is already budgeted, it won't limit PHARMAC's ability to fund other treatments for less rare conditions.

Should PHARMAC request commercial proposals by the end of 2014, funding could begin in early 2015.

For access to the original media release, including a link to the discussion paper, go to: http://www.pharmac.health.nz/news/media-2014-04-08-high-cost-medicines/

To read the full abstract and for information on how to access the full text, go to: http://www.healthpolicyjrnl.com/article/S0168-8510%2814%2900056-6/abstract or contact your local, DHB or organsational library for assistance.

Nord, E., & Johansen, R. (2014). Concerns for severity in priority setting in health care: A review of trade-off data in preference studies and implications for societal willingness to pay for a QALY. Health Policy, 116(2-3), 281–288.

Studying a large group of Medicare patients, researchers found that even modest improvements in the continuity of care among patients with diabetes, congestive heart failure or emphysema were associated with sizable reductions in use of hospital emergency departments and hospitalizations.

The findings, published online by JAMA Internal Medicine, suggest that improving the coordination of care for patients with these three illnesses could save Medicare as much as $1.5 billion per year.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1001/jamainternmed.2014.245 or contact your DHB library, or organisational or local library for assistance.

To read a media release from RAND Coporation about the study, go to:  http://www.rand.org/news/press/2014/03/17/index1.html

Hussey, P.S., et al. (2014). Continuity and the costs of care for chronic disease. JAMA Internal Medicine, 174(5):742-748.

A copy of Dr Ovretveit's presentation, and background documents from the workshop are available to download at:  http://www.hqsc.govt.nz/publications-and-resources/publication/1402/

The report shows what can be done at a local level to improve quality and reduce costs with a relatively small amount of money and within a short timescale of just over a year. It demonstrates the effectiveness of clinically-led improvement projects to improve services. Local clinical leaders were able to identify known quality issues and get their peers on board using local data to demonstrate the problem, with a solution appropriate to their context.

The report groups the Shine projects into four broad categories, depending on the primary focus of the intervention being tested, and summarises the lessons learned. The categories are:

• using information technology to improve services (7 projects)
• changing the way services are organised (12 projects)
• improving access to information for patients and clinicians (5 projects)
• supporting and training staff (8 projects).

The report is available to download and read in full text at:  http://www.health.org.uk/publications/shine-improving-the-value-of-local-healthcare-services/

Health Foundation (2014). Shine: Improving the value of local healthcare services. London: Health Foundation.

From the results of the study, the authors conclude that the intervention "... was a low-cost investment for individuals with established diabetes and may result in medication cost-savings to the health system. Although QALYs were similar between groups, other benefits arising from the intervention should also be considered when determining the overall value of this strategy".

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1016/j.diabres.2013.12.032 or contact your DHB library, or organisational or local library for assistance.

Gordon, L.G., et al. (2014). A cost-effectiveness analysis of a telephone-linked care intervention for individuals with Type 2 diabetes. Diabetes Research and Clinical Practice, 104(1), 103-111.

Studies were included if they contained quantitative economic data, including savings, spending, costs, cost effectiveness analysis, cost benefit analysis, or resource utilization. The authors excluded studies that lacked quantitative data on savings, costs, monetary value, and/or resource utilization.

The authors included seven studies with eight analyses. Of these seven studies, four analyses predicted system-wide savings, with two analyses from the same study. The predicted savings range from $8 (£5, €6) to $3068 (£1868, €2243) per patient. Larger savings accompanied reductions in treatment utilization rates. The impact on utilization rates was mixed. Authors used heterogeneous methods to allocate costs and calculate savings. Quality scores were low to moderate, and risk of bias across the studies was moderate to high, with studies predicting the most savings having the highest risk of bias. The range of issues identified in the studies included the relative absence of sensitivity analyses, the absence of incremental cost effectiveness ratios, and short time periods.

The authors conclude that, although there is evidence to show that patients choose more conservative approaches when they become better informed, there is insufficient evidence, as yet, to be confident that the implementation of patient decision support interventions leads to system-wide savings. Further work—with sensitivity analyses, longer time horizons, and more contexts—is required to avoid premature or unrealistic expectations that could jeopardize implementation and lead to the loss of already proved benefits.

This is an open access article and can be read in free full text at:  http://dx.doi.org/10.1136/bmj.g188

Walsh, T., et al. (2014). Undetermined impact of patient decision support interventions on healthcare costs and savings: Systematic review BMJ, 348:g188.

Based on their analysis of the results, the authors concluded that all the strategies that increased thrombolysis rates resulted in cost savings and improved patient quality of life. "Using realistic estimates of effectiveness, the change strategy with the largest potential benefit was that of better recording of onset time, which resulted in 3.3 additional quality-adjusted life years and a cost saving of US $46 000 per 100 000 population". 

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1161/STROKEAHA.113.003216 or contact your DHB library, or organisational or local library for assistance.

Penaloza-Ramos, M.C., et al. (2014). Cost-effectiveness of optimizing acute stroke care services for thrombolysis. Stroke, 45, 553-562.

A totla of 48,538 Medicare members received the post-discharge telephone intervention, and 4,504 (9.3%) were readmitted to hospital within 30 days, compred with 5,598 controls (11.5%). The authors note that the closer the telephone intervention was to the date of discharge the greater the reduction in readmissions. In addition, physician office visits increased in the intervention group. The authors describe the cost savings as a result of the intervention and conclude that support for patients after hospital discharge "... warrants further development".

This paper is available to read in full text at:  http://online.liebertpub.com/doi/full/10.1089/pop.2012.0084

Costantino, M.E., et al. (2013). The influence of a postdischarge intervention on reducing hospital readmissions in a Medicare population. Population Health Management, 16(5): 310–316.

District health boards around New Zealand are saving millions of dollars by working together to reduce back office costs, with the savings reinvested back into frontline health services for their communities.

Health Minister Tony Ryall visited the Golden Bay Integrated Family Health Centre today. Their local DHB, Nelson Marlborough, saved nearly $2 million in back office costs through regional procurement in the last financial year.

“By purchasing goods and services together, from medical gases to postage-paid envelopes, DHBs are able to harness the power of bulk purchasing and get the most out of every health dollar,” says Mr Ryall.

“Last financial year, the five South Island DHBs made combined savings of nearly $15 million through the South Island Alliance regional procurement programme.

“The Alliance has also introduced a South Island wide programme for young people with eating disorders. Doctors in Nelson, Blenheim, Greymouth, Christchurch, Timaru, Dunedin and Invercargill are now able to provide effective therapy for young people and their families closer to home.

“The Alliance is currently working on number of IT projects, including a single patient administration system across the South Island. The goal is to give health professionals better access to their patient’s health information to improve patient care and clinical decision making.

“Along with Health Benefits Limited, the South Island Alliance is another good example of how patient care can be improved when DHBs work together,” says Mr Ryall.

The South Island Alliance is made up of representatives from the five South Island DHBs who work collaboratively to develop more innovative and efficient health services.

The authors investigated differences in clinical outcomes and costs between the new and old models. They concluded from their study that a centralised model for acute stroke care across an entire metropolitan city appears to have reduced mortality for a reduced cost per patient, predominately as a result of reduced hospital length of stay.

This is an open access article and is available to read in full text at: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0070420

Hunter, R.M., et al. (2013). Impact on clinical and cost outcomes of a centralized approach to acute stroke care in London: A comparative effectiveness before and after model. PLoS ONE 8(8), e70420.

The results of the survey completed by these clinicians, found that 67.0% overall thought that a comprehensive stroke unit model was the best model. Seventy-three% of doctors and 79% of allied health preferred a comprehensive stroke unit model, whereas only 57% of nurses did so. Of doctors, rehabilitation specialists were most likely to favour a comprehensive model and neurologists the least. The main perceived advantages of a comprehensive stroke unit model were reduced cost and improved functional outcomes; perceived disadvantages were increased workload and unwell patients unable to participate in rehabilitation. Main perceived barriers to establishing a comprehensive stroke unit model were lack of space, money, staffing and time.

To read the full abstract, and for information on how to access the full text, go to: http://www.publish.csiro.au/?paper=AH12026  or contact your DHB library, or organisational or local library for assistance.

O'Rourke, F., et al. (2013). Preferences, barriers and facilitators for establishing comprehensive stroke units: A multidisciplinary survey. Australian Health Review, [published online 24 May 2013].

The 2012 HHI Milestone Report summarizes the Initiative’s first year of progress, with 370 HHI enrollees of all sizes and types contributing their experiences to the data. Some of the report’s key findings include:

• More than 50 million pounds of materials recycled, plus an additional 61.5 million pounds of construction and demolition waste kept out of landfills through reuse and recycling.
• About $32 million in savings resulting from single-use medical device reprocessing.
• Nearly $9 million spent on local/sustainable food options.
• Almost $19 million spent on healthier, PVC/DEHP-free medical products.

Access to the full text of the report is free online at: http://healthierhospitals.org/sites/default/files/IMCE/public_files/Pdfs/hhi_2012_milestone_report.pdf

The authors identified large reductions in number of hospitalisations, length of average hospital stay, and, to a lesser extent, number of emergency room visits, as a result of the telemonitoring intervention, although home visits by nurses increased both during and after the intervention.

Overall, the telehealth programme resulted in significant savings: the equivalent of over CAD1,557 per patient (as calculated on an annualised basis). The authors recommend additional assessments to confirm the cost-effectiveness of this mode of care delivery.

To view the full abstract and for information on how to access the full text, go to: http://dx.doi.org/10.1017/S0266462313000111 or contact your DHB library, or organisational or local library for assistance.

Paré, G., et al. (2013). Home telemonitoring for chronic disease management: An economic assessment. International Journal of Technology Assessment in Health Care, 29(2), 155-161.

The same evaluation is the subject of a white paper that is available in full text at: http://www.telushealth.com/docs/default-source/whitepapers/home-monitoring-for-chronic-disease-management-an-economic-assessment.pdf?sfvrsn=12

Pharmacy staff at Waikato District Health Board's hospitals have been working hard with clinicians to identify ways reduce the amount the DHB spends on pharmaceuticals.

Several initiatives over the past 12 months have resulted in a tightening up in the way the hospitals use medicines, improvements to prescribing and reduced wastage.  These initiatives include:

• working with ward managers to streamline quantities of stock held on the ward. Not only this has resulted in reduced stock holding and increased turnover of stock but has also identified areas for improvement with the type of stock held and the ways of ordering medicines. 
• working with theatre staff (anaesthetists) on the way inhaled anaesthetic agents are used - and the DHB has recently negotiated a reduced price for an intravenous anaesthetic agent.  This has resulted in at least $50,000 reduction in spend per year. 
• working with haematology and nursing staff to look at the way the hospitals use a class of medicines for promoting white blood cell growth (GCSF) and an antifungal agent (posaconazole).  By modifying the way these medicines are prescribed and provided to the patient, the hospitals have identified over $270,000 per year savings to the hospitals' budget.

Mark Spittal, group manager Waikato and Thames Hospitals, described the initiatives as "sustained savings from changes to clinical practice across several groups of clinical staff."

Over almost 20 years, the  California Tobacco Control Program is associated with a reduction in cigarette sales of around 6.8 billion packs, and with a cumulative reduction in 8.79 million person-years of smoking. The cumulative savings in healthcare expenditures is identified as $134 billion for the years 1989 to 2008.

The results indicate that the California Tobacco Control Program was effective in reducing both prevalence of smoking and average cigarette consumption per smoker, and that both measures of smoking behavior have a significant relationship to per capita healthcare expenditures.

This is an open access article and is available to read and download in full text at: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0047145

Lightwood J., Glantz S.A. & Fielding R. (2013). The effect of the California Tobacco Control Program on smoking prevalence, cigarette consumption, and healthcare costs: 1989–2008. PLoS ONE, 8(2) e47145. 

The plan identifies how everybody – not just pharmacists, GPs and care home staff, but also patients and the public – can stop avoidable medicines wastage.

The report is available to read in full text at: http://www.dh.gov.uk/health/2012/12/medicines-reduced-waste/

The aims of the study were to understand the requirements of mobile working, and to demonstrate whether increased productivity and efficiency can be achieved by making changes to working processes.

The findings include:

• significant increases in productivity can be achieved, as demonstrated by large increases in contact activity
• significant increases in time spent with patients following deployment of mobile devices – John Taylor Hospice near Birmingham found that using laptops more than doubled the amount of time clinicians could spend with patients
• unnecessary journeys can be reduced, even where clinical activity is increased – North Tees and Hartlepool Foundation Trust found each clinician could save as much as £889 per year as driving to and from hospital in between visits fell, because health workers could log patient information on a laptop
• time spent travelling can be reduced
• data duplication can be reduced significantly, freeing up clinical time
• ‘no access’ visits can be reduced significantly – the study found NHS Northampton could save as much as £978 per clinician, per year
• significant saving in referrals can be achieved
• significant savings in admissions can be achieved.

The report is available to read in full text at: http://www.dh.gov.uk/health/2013/01/mobile-health-worker/

Department of Health (2013). National Mobile Health Worker Project: Final report. London: Department of Health.

The study found that measures such as more use of text messages for negative test results, electronic prescribing and electronic patient records could improve care, allow health professionals to spend more time with patients and save billions of pounds.

The report says that a potential £4.4billion per year could be reinvested in improving care by making better use of information and technology.

The report is available to read in full text at: http://www.dh.gov.uk/health/2013/01/study-digital-technology/

PricewaterhouseCoopers (2013). A review of the potential benefits from the better use of information and technology in  health and social care: Final report. London: PricewaterhouseCoopers.

The authors estimate that if the health care industry conserved energy, reduced waste, and purchased operating supplies more efficiently, it could save more than $5 billion over five years and $15 billion over a decade.

The report is available to read in full text at: http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Nov/Sustainable-Hospitals.aspx

Kaplan, S., et al. (2012). Can sustainable hospitals help bend the health care cost curve? [New York]: The Commonwealth Fund.

"Consistent with prior randomized trials, our introduction of decision aids was associated with 26 percent fewer hip replacement surgeries, 38 percent fewer knee replacements, and 12–21 percent lower costs over six months. These findings support the concept that patient decision aids for some health conditions, for which treatment decisions are highly sensitive to both patients’ and physicians’ preferences, may reduce rates of elective surgery and lower costs".

This article is available to read in full text at: http://content.healthaffairs.org/content/31/9/2094.full

Arterburn, D., et al. (2012). Introducing decision aids at Group Health was linked to sharply lower hip and knee surgery rates and costs. Health Affairs, 31(9), 2094-2104.

Patients show comparable or better clinical outcomes compared with similar inpatients, and they show higher satisfaction levels. Savings were mainly derived from lower average length-of-stay and use of fewer lab and diagnostic tests. 

To read the full abstract and for information on how to access the full text, go to: http://content.healthaffairs.org/content/31/6/1237.short or contact your local or organisational library for assistance.

Cryer, L., et al. (2012). Costs for ‘hospital at home’ patients were 19 percent lower, with equal or better outcomes compared to similar inpatients. Health Affairs, 31(6), 1237-1243

Based on the findings of the study, the authors conclude that  "... nurse specialists give diabetes care that is similar to care provided by physicians in terms of quality of life and economic value. Instigating a nurse specialist as central carer yields opportunities to generate cost savings. Developing interventions which also focus on prevention of complications is recommended when aiming for long-term organisational cost savings".

To read the full abstract and for information on how to access the full text, go to: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2011.05797.x/abstract or contact your local or organisational library for assistance.

Arts, E.E.A., et al. (2012). The cost-effectiveness of substituting physicians with diabetes nurse specialists: A randomized controlled trial with 2-year follow-up. Journal of Advanced Nursing, 68(6), 1224-1234.

Xcelr8 is a professional development programme where clinicians and managers work together covering topics such as leadership skills, patient flow, capacity forecasting and planning, and learning to make effective and efficient use of resources.

To read the full story, go to: http://www.scoop.co.nz/stories/GE1206/S00002/transport-of-cardiac-patients.htm

Twenty-nine studies were included in the review. Four had two intervention arms which were treated as independent studies, giving a total of 33 estimates.  All studies except one reported a benefit from sending reminders to patients prior to their appointment. The synthesis suggests that the weighted mean relative change in non-attendance was 34% of the baseline non-attendance rate. Automated reminders were less effective than manual phone calls (29% vs 39% of baseline value). There appeared to be no difference in non-attendance rate, whether the reminder was sent the day before the appointment or the week before. Cost and savings were not measured formally in any of the papers, but almost half of them included cost estimates. The average cost of using either SMS, automated phone calls or phone calls was €0.41 per reminder.

The authors conclude that, although formal evidence of cost-effectiveness is lacking, the implication of the review is that all hospitals should consider using automated reminders to reduce non-attendance at appointments.

Hasvold, P.E. & Wootton, R. (2012). Use of telephone and SMS reminders to improve attendance at hospital appointments: a systematic review. Journal of Telemedicine and Telecare, 17 (7), 358-364.

This an open access article available to read in full text online at: http://jtt.rsmjournals.com/content/17/7/358.full

This publication from the Enhanced Recovery Partnership outlines the benefits to patients and the NHS that implementation of enhanced recovery principles can present.

Enhanced Recovery Partnership (2012). Fulfilling the potential: A better journey for patients and a better deal for the NHS. [London]: NHS Improvement.

This report is available in full text online at: http://www.improvement.nhs.uk/documents/er_better_journey.pdf

For more detail on the Enhanced Recovery programme, go to: http://www.improvement.nhs.uk/enhancedrecovery/

A study led by Dr Jaikishan Desai from Victoria’s Health Services Research Centre in the School of Government analysed hospital productivity over the three years by looking at the number of people treated as inpatients, outpatients or in emergency departments, for each dollar of expenditure incurred by district health boards.

Dr Desai says that importantly, the study also shows increases in hospital efficiency in the same period.

He says researchers looked at three different measures of efficiency, covering technology change, technical efficiency and allocation of staff and resources, and all showed an improvement between 2007 and 2009.

The team was surprised by the findings, says Dr Desai, and checked the analysis using three different methods, all of which showed significant improvements in productivity and efficiency.

He says there is already international interest in the findings because they run counter to widely held views that hospital productivity is falling in developed countries.

The research also shows that the length of inpatient stays is dropping and more people are instead attending outpatient clinics.

"Hospitals clearly are trying to shift towards lower cost treatments," says Dr Desai.

The study did not look at how this move is impacting on patient outcomes.

Dr Desai says the research findings are being written up for publication in academic journals.

"Internationally, there is little research on how hospital productivity changes over time despite its implications for funding of health services.

"Hospitals take a big chunk of government spending on health services so it’s important to know what value you are getting for the money."

Dr Desai says an area of concern is the limited analysis of health data that takes place in New Zealand.

"We are very good at gathering information through questionnaires and surveys but less adept at finding out what it is telling us.

"There are some very capable people with research skills, but relatively little money is allocated for analysis of health services data—much of it goes to epidemiological and medically oriented studies. It’s a shame because finding new cures and treatments is not enough—we also have to figure out the best way of delivering them to the population."

The research was done in collaboration with the University of Auckland and the University of Otago, Christchurch and funded by the Health Research Council.

Media release, Victoria University, 1 May 2012

The International Association of Diabetes and Pregnancy Study Group (IADPSG) recently recommended new criteria for diagnosing gestational diabetes mellitus (GDM). This study was undertaken to determine whether adopting the IADPSG criteria would be cost-effective, compared with the current standard of care. The authors developed a decision analysis model comparing the cost-utility of three strategies to identify GDM: 1) no screening, 2) current screening practice, or 3) screening practice proposed by the IADPSG. Assumptions included that 1) women diagnosed with GDM received additional prenatal monitoring, mitigating the risks of preeclampsia, shoulder dystocia, and birth injury; and 2) GDM women had opportunity for intensive post-delivery counseling and behaviour modification to reduce future diabetes risks. The primary outcome measure was the incremental cost-effectiveness ratio. Analysis found that the IADPSG recommendation for glucose screening in pregnancy is cost-effective. The model is most sensitive to the likelihood of preventing future diabetes in patients identified with GDM using postdelivery counseling and intervention.

The briefing is designed to give providers and commissioners information on trends in the use of hospital beds to help them decide where to focus their attention over the coming year. Findings from the data show that 80% of emergency admissions who stay for more than two weeks are patients aged over 65, therefore suggesting that focusing on reducing the length of stay for older people has the most potential for reducing hospital bed use.

King's Fund. (2011). Data briefing: Emergency bed use - what the numbers tell us. London: King's Fund.

To access the full data briefing, go to: http://www.kingsfund.org.uk/publications/emergency_bed_use.html

A total of 103,829 cardiac, 216,199 vascular, 142,562 non-cardiac thoracic, 45,687 solid organ, 362,512 general, 384,132 reproductive organ, 246,815 knee/hip replacement, and 107,187 spinal surgeries were identified. Overall, the rate of bleeding-related complications was 29.9% and ranged from 7.5% to 47.4% for reproductive organ and cardiac, respectively. Overall, incremental LOS associated with bleeding-related complications or transfusions (unadjusted for covariates) was 6.0 days and ranged from 1.3 to 9.6 days for knee/hip replacement and non-cardiac thoracic, respectively. The incremental cost per hospitalization associated with bleeding-related complications and adjusted for covariates was highest for spinal surgery ($17,279) followed by vascular ($15,123), solid organ ($13,210), non-cardiac thoracic ($13,473), cardiac ($10,279), general ($4,354), knee/hip replacement ($3,005), and reproductive organ ($2,805).

This study characterizes the increased hospital LOS and cost associated with bleeding-related complications and/or transfusions occurring as a consequence of surgery, and supports implementation of blood-conservation strategies.

Stokes, M.E., et al. (2011). Impact of bleeding-related complications and/or blood product transfusions on hospital costs in inpatient surgical patients. BMC Health Services Research, 11:135

This is an open access article and is available in full text at: http://www.biomedcentral.com/1472-6963/11/135

A mathematical programming model was developed to calculate optimal allocations for the Dutch population of the following interventions: smoking cessation support, diet and exercise to reduce overweight, statins, and medication to reduce blood pressure. Outcomes were total lifetime health care costs and QALYs. Budget sizes were varied and the division of resources between the general population and diabetes patients was assessed.

Full implementation of all interventions resulted in a gain of 560,000 QALY at a cost of euro 640 per capita, about euro 12,900 per QALY on average. The large majority of these QALY gains could be obtained at incremental costs below euro 20,000 per QALY. Low or high budgets (below euro 9 or above euro 100 per capita) were predominantly spent in the general population. Moderate budgets were mostly spent in diabetes patients.

Conclusions: Major health gains can be realized efficiently by offering prevention to both the general and the diabetic population. However, a priori setting a specific distribution of resources is suboptimal. Resource allocation models allow accounting for capacity constraints and program size in addition to efficiency.

Feenstra, T.L., et al. (2011). Targeted versus universal prevention. A resource allocation model to prioritize cardiovascular prevention. Cost Effectiveness and Resource Allocation, 9:14

Available to read in free full text at: http://www.resource-allocation.com/content/9/1/14/abstract

Each year the programme focuses on a different aspect of healthcare quality that reflects a key issue facing the UK health service.

In its second year, 14 new smart thinking teams from across the UK have taken up the Shine 2011 challenge to find new approaches to delivering healthcare that reduce the need for acute hospital care while improving quality and saving money.

The Health Foundation is delivering Shine with Springfield Consultancy, who will support the teams by providing consultancy and advice on management and evaluation strategies.

During the course of the 12 month programme, the 14 teams will be supported to put their approach into practice for the first time and gather the evidence of impact and effectiveness.

The attached report describes each of the 14 projects.

This article appeared in the HIIRC Update, October 2011

Related articles from that issue:

Cochrane review: The effect of financial incentives on the quality of health care provided by primary care physicians

Systematic review of trends in emergency department attendances: An Australian perspective

Elective surgical referral guidelines - background educational material or essential shared decision making tool? A survey of GPs' in England

Teamwork and team performance in multidisciplinary cancer teams: Development and evaluation of an observational assessment tool

Self-care of school-age children with diabetes: An integrative review

How cardiac patients describe the role of their doctors in smoking cessation: A qualitative study (Australia)

"The evidence does show that community-based services can, under the right conditions, provide quality of care that is as good as that in hospital and, in some instances, at a lower cost. Findings on patient satisfaction are less equivocal; ease of access, travel and shorter waiting times are typically cited as improvements when care is closer to home.

The review also identified that there is particular potential for community-based services to help reduce NHS costs by promoting early discharge from hospital for patients who no longer need intensive acute care, but are not yet ready to fend for themselves at home. However, for significant cost savings to be realised moving care into the community needs to be associated with active reductions or decommissioning of hospital-based services.     

The conclusions are appropriately cautious, however. The majority of the published evidence fails to contain robust cost information on infrastructure, planning and start-up costs. Furthermore, much of the evidence is based on small, highly [patient] selective pilots making it difficult to make system-wide generalisations for a broader range of patients".   

Munton, T., et al. (2011). Getting out of hospital? The evidence for shifting acute inpatient and day case services from hospitals into the community. London: The Health Foundation.

To read the full report, go to: http://www.health.org.uk/publications/getting-out-of-hospital/

There are, however, changes under way within leading organizations that suggest significant improvements in quality and value can be achieved. In 2008, the Leapfrog Group’s Hospital Recognition Program began identifying hospitals that have made “big leaps in health care safety, quality, and customer value.” Thirteen hospitals out of nearly 1,300 who voluntarily submitted data in 2008 achieved top scores in quality of care while keeping resource use low.

To learn what opportunities exist for all hospitals to achieve greater efficiency, case studies were undertaken of four of the 13 Leapfrog Group–designated “Highest Value Hospitals.” These included Fairview Southdale Hospital in Edina, Minn., North Mississippi Medical Center in Tupelo, Miss., Park Nicollet Methodist Hospital in St. Louis Park, Minn., and Providence St. Vincent Medical Center in Portland, Ore. This paper offers a synthesis of lessons from their experiences.

J. N. Edwards, S. Silow-Carroll, and A. Lashbrook (2011). Achieving efficiency: Lessons from four top-performing hospitals. The Commonealth Fund.

Synthesis report and individual case studies available in full text at: http://www.commonwealthfund.org/Content/Publications/Case-Studies/2011/Jul/Efficiency-Series.aspx

The review concludes that greater coordination of care has the potential to reduce costs and should be a major consideration for how to improve quality and save money in the current funding situation. However, while better process coordination could release significant savings, these approaches also have high risks and costs.

The review summarises and grades the strength of the evidence, so that it is clear which approaches are the most robustly evaluated. Some of the evidence is not conclusive, as many changes that aim to improve coordination have not been well evaluated.

The final section of the report suggests how patients, health service providers, commissioners, regulators and professional organisations could all take some responsibility for improving clinical coordination and thus reducing duplication, waste and thus the overall costs of healthcare.

Øvretveit, J. (2011). Does clinical coordination improve quality and save money? A review of the evidence. London: Health Foundation.

The report is available in full text at: http://www.health.org.uk/publications/does-clinical-coordination-improve-quality-and-save-money/

The tool consists of five modules — Ward Module, Patient Care Module, Diagnosis Module, Treatment Module, and Patient Module — that qualitatively identify opportunities for waste reduction. Each module includes clearly articulated waste types, worksheets, and instructions.

The Hospital Inpatient Waste Identification Tool is designed to provide a snapshot of potential areas of waste within a hospital, as identified by frontline clinical staff. Once this snapshot is obtained, representatives of the hospital’s frontline clinical staff, finance department, and leadership engage in a process of enriched review and analysis of the findings to prioritise and implement waste reduction initiatives.

Hospitals can use the Waste Identification Tool as one key strategy in an ongoing process of identifying, assessing the impact of, and reducing waste by engaging both frontline staff and leadership. The tool may be adapted by individual organisations to maximise its effectiveness within their clinical environment, or to apply the tool to non-acute care settings.

This white paper describes the Hospital Inpatient Waste Identification Tool, instructs users in how to make best use of it, provides worksheets and instructions, and offers methods for using Waste Identification Tool findings in a structured and systematic process of prioritising and implementing waste reduction projects in the inpatient hospital setting. Guidance for customising the tool is included in the paper.

To access the free download, go to: http://www.ihi.org/IHI/Results/WhitePapers/HospitalInpatientWasteIDToolWhitePaper.htm