Cost-effectiveness of England's national 'Safe At Home' scheme for reducing hospital admissions for unintentional injury in children aged under 5

BACKGROUND

Injuries in children aged under 5 years most commonly occur in the home and disproportionately affect those living in the most disadvantaged communities. The 'Safe at Home' (SAH) national home safety equipment scheme, which ran in England between 2009 and 2011, has been shown to reduce injury-related hospital admissions, but there is little evidence of cost-effectiveness.

MATERIALS AND METHODS

Cost-effectiveness analysis from a health and local government perspective. Measures were the incremental cost-effectiveness ratio per hospital admission averted (ICER) and cost-offset ratio (COR), comparing SAH expenditure to savings in admission expenditure. The study period was split into three periods: T1 (years 0-2, implementation); T2 (years 3-4) and T3 (years 5-6). Analyses were conducted for T2 versus T1 and T3 versus T1.

RESULTS

Total cost of SAH was £9 518 066. 202 223 hospital admissions in the children occurred during T1-3, costing £3 320 000. Comparing T3 to T1 SAH reduced admission expenditure by £924 per month per local authority and monthly admission rates by 0.5 per local authority per month compared with control areas. ICER per admission averted was £4209 for T3 versus T1, with a COR of £0.29, suggesting that 29p was returned in savings on admission expenditure for every pound spent on SAH.

CONCLUSION

SAH was effective at reducing hospital admissions due to injury and did result in some cost recovery when taking into admissions only. Further analysis of its cost-effectiveness, including emergency healthcare, primary care attendances and wider societal costs, is likely to improve the return on investment further.

Impact of the national home safety equipment scheme 'Safe At Home' on hospital admissions for unintentional injury in children under 5: a controlled interrupted time series analysis

BACKGROUND

Unintentional home injuries are a leading cause of preventable death in young children. Safety education and equipment provision improve home safety practices, but their impact on injuries is less clear. Between 2009 and 2011, a national home safety equipment scheme was implemented in England (Safe At Home), targeting high-injury-rate areas and socioeconomically disadvantaged families with children under 5. This provided a 'natural experiment' for evaluating the scheme's impact on hospital admissions for unintentional injuries.

METHODS

Controlled interrupted time series analysis of unintentional injury hospital admission rates in small areas (Lower Layer Super Output Areas (LSOAs)) in England where the scheme was implemented (intervention areas, n=9466) and matched with LSOAs in England and Wales where it was not implemented (control areas, n=9466), with subgroup analyses by density of equipment provision.

RESULTS

57 656 homes receiving safety equipment were included in the analysis. In the 2 years after the scheme ended, monthly admission rates declined in intervention areas (-0.33% (-0.47% to -0.18%)) but did not decline in control areas (0.04% (-0.11%-0.19%), p value for difference in trend=0.001). Greater reductions in admission rates were seen as equipment provision density increased. Effects were not maintained beyond 2 years after the scheme ended.

CONCLUSIONS

A national home safety equipment scheme was associated with a reduction in injury-related hospital admissions in children under 5 in the 2 years after the scheme ended. Providing a higher number of items of safety equipment appears to be more effective in reducing injury rates than providing fewer items.

Accuracy and optimal timing of activity measurements in estimating the absorbed dose of radioiodine in the treatment of Graves' disease

Calculation of the therapeutic activity of radioiodine (131)I for individualized dosimetry in the treatment of Graves' disease requires an accurate estimate of the thyroid absorbed radiation dose based on a tracer activity administration of (131)I. Common approaches (Marinelli-Quimby formula, MIRD algorithm) use, respectively, the effective half-life of radioiodine in the thyroid and the time-integrated activity. Many physicians perform one, two, or at most three tracer dose activity measurements at various times and calculate the required therapeutic activity by ad hoc methods. In this paper, we study the accuracy of estimates of four 'target variables': time-integrated activity coefficient, time of maximum activity, maximum activity, and effective half-life in the gland. Clinical data from 41 patients who underwent (131)I therapy for Graves' disease at the University Hospital in Pisa, Italy, are used for analysis. The radioiodine kinetics are described using a nonlinear mixed-effects model. The distributions of the target variables in the patient population are characterized. Using minimum root mean squared error as the criterion, optimal 1-, 2-, and 3-point sampling schedules are determined for estimation of the target variables, and probabilistic bounds are given for the errors under the optimal times. An algorithm is developed for computing the optimal 1-, 2-, and 3-point sampling schedules for the target variables. This algorithm is implemented in a freely available software tool. Taking into consideration (131)I effective half-life in the thyroid and measurement noise, the optimal 1-point time for time-integrated activity coefficient is a measurement 1 week following the tracer dose. Additional measurements give only a slight improvement in accuracy.

Factors associated with Medicare beneficiary complaints about quality of care

This article examines the number and types of formal complaints about quality of care that were made by Medicare beneficiaries and submitted to the California Peer Review Organization (PRO) during the period July 1, 1995-December 30, 1996. Logistic regression models were used to analyze the complaints in terms of sociodemographic factors, enabling factors (income and health maintenance organization [HMO] membership), diagnoses, and primary service providers. The complaint rate was found to be very low, and only 13% of complaints were confirmed by the PRO. HMO members and members receiving physician care and outpatient/emergency room care were more likely to complain about denials of or delays in services or the failure to be referred to specialists than were members in fee-for-service plans and those receiving other types of provider care. Complaints about poor nursing care were associated with receiving skilled nursing/rehabilitation care. Complaints about care that resulted in injury were associated with the denial of care, failure to be referred to a specialist, poor medical care, and poor communications. Complaints about care that led to disability were associated with medical errors, whereas those that led to death were associated with misdiagnosis and premature hospital discharge. It would be valuable for PROs to focus their complaint review efforts on common types of complaints in different settings. A review of PRO procedures should be undertaken to understand why so few complaints are submitted and confirmed.

Medicare beneficiary complaints about quality of care

This study examined all Medicare beneficiary complaints about quality of care submitted to the California Peer Review Organization (PRO) over 18 months. The complaint rate was low, and a medical record review by the PRO only confirmed 13% of the complaints. Managed Care Organization (MCO) members filed significantly more complaints about denial and/or delays in receiving services and the failure to refer to specialists. Fee-for-service complaints focused on inpatient hospital services, particularly premature discharge, discharge planning, admission necessity, and unnecessary tests. The PRO review process took over 7 months, and the findings were generally not released to the complainants.

Self-efficacy beliefs and change in cognitive performance: MacArthur Studies of Successful Aging

Data from a cohort of relatively high functioning, older men and women were used to test the hypothesis that stronger self-efficacy beliefs predict better maintenance of cognitive performance. Structural equation modeling revealed that stronger baseline instrumental efficacy beliefs predicted better verbal memory performance at follow-up among men but not among women, controlling for baseline verbal memory score and sociodemographic and health status characteristics. For both men and women there were no significant associations between either type of self-efficacy beliefs and measures of nonverbal memory, abstraction, or spatial ability. Consistent with previous research showing relationship between baseline cognitive performance and change in self-efficacy beliefs, better abstraction ability was also predictive of increase in instrumental efficacy beliefs among the men.

Self-efficacy beliefs and change in cognitive performance: MacArthur Studies of Successful Aging

Data from a cohort of relatively high functioning, older men and women were used to test the hypothesis that stronger self-efficacy beliefs predict better maintenance of cognitive performance. Structural equation modeling revealed that stronger baseline instrumental efficacy beliefs predicted better verbal memory performance at follow-up among men but not among women, controlling for baseline verbal memory score and sociodemographic and health status characteristics. For both men and women there were no significant associations between either type of self-efficacy beliefs and measures of nonverbal memory, abstraction, or spatial ability. Consistent with previous research showing relationship between baseline cognitive performance and change in self-efficacy beliefs, better abstraction ability was also predictive of increase in instrumental efficacy beliefs among the men.

Early occurrence of end-stage renal disease in a patient with infantile nephropathic cystinosis

We report the case of a patient with infantile nephropathic cystinosis who required renal transplantation at age 30 months. Exhaustive evaluation did not identify a cause of progressive renal failure other than cystinosis. The patient's genetic lesion was allelic with those of other patients with cystinosis; fusion of this patient's fibroblasts with fibroblasts from another patient with infantile nephropathic cystinosis did not demonstrate complementation of the biochemical defect.

Durability of passive measles antibody in Jamaican children

Measles antibody titres were determined by haemagglutination inhibition and by neutralization in 221 sets of serum collected from delivering mothers, umbilical cords, and infants when about six months of age. Radio-immunoassay was also used to measure antibody in 120 sera. Total IgG concentration was determined in the infant sera. All mothers had measles antibody and the mean titre was high. At the time of birth, measles antibody had been further concentrated in the infant. Nevertheless, many children lost protective titres before six months of age. The rate of loss was correlated with the infant's total serum IgG so that high IgG levels at six months correlated with rapid loss of measles-specific antibody. It is suggested that in homes where sanitation is poor, antibody is made to many agents at an early age. To maintain physiological balance, homeostatic mechanisms then increase the rate of catabolism of all IgG, including that passively acquired. In keeping with its stage of sanitary development, vaccination in Jamaica can profitably be given earlier than in the United States, but it must be later than in many African countries.

Fetal body and breathing movements as predictors of intraamniotic infection in preterm premature rupture of membranes

A prospective study of fetal behavior in cases complicated with preterm premature rupture of membranes was conducted in 41 patients. The length of time and the number of fetal breathing and gross body movements were correlated with the amniotic fluid culture results. An episode of fetal activity (body movements and breathing movements) of greater than or equal to 30 seconds during 30 minutes of observation was associated with the absence of intraamniotic infection in 100% of the cases. On the other hand, the absence of fetal breathing movements and gross body movements of less than a 50 second duration during 30 minutes of observation was associated with positive amniotic fluid cultures in all cases. If an episode of fetal breathing movements was present but lasted less than 30 seconds and/or the total time of gross body movements was greater than 50 seconds, 64% of patients had an intraamniotic infection.

Amniostat-FLM: an initial clinical trial with both vaginal pool and amniocentesis samples

Amniostat-FLM, a new rapid slide agglutination test, was compared with thin-layer chromatography as a method for detecting phosphatidylglycerol in amniotic fluid. This is the first reported use of Amniostat-FLM to evaluate vaginal pool and contaminated vaginal pool amniotic fluid. One hundred one of 161 amniotic fluid samples were collected from the vaginal pool. Thirty-nine of these were contaminated. Vaginal pool amniotic fluid, whether contaminated or not, did not adversely effect the ease of performance, reliability, or interpretation of Amniostat-FLM. This test seems ideally suited to institutions where 24-hour availability of thin-layer chromatography is not available. In institutions where it is available, Amniostat-FLM could be used as a screening test. Amniostat-FLM was found to be significantly less sensitive when compared with thin-layer chromatography in detecting the presence of phosphatidylglycerol. At our institution the screening of amniotic fluid samples with Amniostat-FLM before use of thin-layer chromatography was only cost effective at greater than or equal to 34 weeks of gestation.

Differential substrate oxidation by dissociated brain cells and homogenates during development

The rates of oxidation of 3-hydroxy[3-14C]butyrate, [3-14C]acetoacetate and [6-14C]glucose were compared by using two different preparations of brain from the same animals (i.e. whole homogenates and dissociated brain cells) at various ages during development. In homogenates the rates of oxidation of 3-hydroxy[3-14C]butyrate and [3-14C]acetoacetate were high in young rats and low in adults, and were significantly higher at most ages during development than those obtained for intact cells. In contrast, rates of [6-14C]glucose oxidation by homogenates and intact cells were essentially the same at early ages; however, the rate by homogenates did not change throughout development, whereas that by intact cells increased severalfold by adulthood. In adult animals the initial glucose concentration affected the rate of glucose oxidation in homogenates, but not in intact cells. These data suggest a role for the intact cell membrane in the regulation of alternative substrate utilization by brain cells and that this process changes during development. However, the data may reflect selective differences in the cellular and subcellular components in these two preparations.

Dream analysis in brief psychotherapy

Dream analysis increases participation in brief analytic psychotherapy through interpretation of currently meaningful content. This transition and the sharing of the dream with the therapist helps develop increased self-awareness and recognition of the patient's ability to make self-initiated decisions rather than remain helpless in the face of current conflict.