Ciaran O'Neill - Academia.edu (original) (raw)
Papers by Ciaran O'Neill
Diabetes Therapy, 2017
Introduction: As part of a control strategy current guidance in the UK recommends more intense su... more Introduction: As part of a control strategy current guidance in the UK recommends more intense surveillance of HbA1C levels among those of Southeast Asian or Chinese ethnicity above specified BMI thresholds. The objective of this study was to determine whether disparities in the identification and control of diabetes in England persisted despite these guidelines and assess current strategies in light of these findings. Methods: Data were extracted from the 2013 Health Survey for England that included ethnicity, BMI status and HbA1C levels. Descriptive statistics and logistic regression analyses were used to examine relationships among undetected diabetes, poorly controlled diabetes and a range of covariates including ethnicity and BMI. Concentration indices were used to examine the socioeconomic gradient in disease detection and control among and between ethnic groups. Results: In regression models that controlled for a range of covariates Asians were found to have a 5% point higher risk of undetected diabetes than Whites. With respect to disease management, Bangladeshis and Pakistanis were found to be at a 28% point and 21% point higher risk of poor disease control respectively than Whites. Concentration indices revealed better disease control among more affluent Whites than poor Whites, no significant pattern between income and disease management was found among Pakistanis and poorer disease control was more evident among more affluent than poorer Bangladeshis. Conclusion: In the UK current guidance recommends practitioners consider testing for diabetes among Southeast Asians and Chinese where BMI exceeds 23. Our findings suggest that the risk experienced by Asians in disease detection is independent of BMI and may warrant a more active screening policy than currently recommended. With respect to disease management, our findings suggest that Indians and Pakistanis experience particularly high levels of poor disease control that may also be usefully reflected in guidance.
BMC pregnancy and childbirth, Jan 24, 2015
There is no consensus on the effect of gestational diabetes mellitus (GDM) on health-related qual... more There is no consensus on the effect of gestational diabetes mellitus (GDM) on health-related quality of life (HRQOL) for the mother in the short or long term. In this study we examined HRQOL in a group of women who had GDM in the index pregnancy 2 to 5 years previously and compared it to a group of women with normal glucose tolerance (NGT) in the index pregnancy during the same time period. The sample included 234 women who met International Association of Diabetes Study Groups (IADPSG) criteria for GDM in the index pregnancy and 108 who had NGT. The sample was drawn from the ATLATIC-DIP (Diabetes In Pregnancy) cohort - a network of antenatal centers along the Irish Atlantic seaboard serving a population of approximately 500,000 people. HRQOL was measured using the visual analogue component of the EQ-5D-3 L instrument in a cross-sectional survey. The difference in HRQOL between GDM and NGT groups was not significant when adjusted for the effects of the covariates. HRQOL was negative...
Expert review of pharmacoeconomics & outcomes research, Jan 17, 2015
Co-testing (cytology plus human papillomavirus DNA testing) as part of cervical cancer surveillan... more Co-testing (cytology plus human papillomavirus DNA testing) as part of cervical cancer surveillance in Ireland increases one-time testing costs. Of interest to policy makers was the long-term impact of these costs accompanied by decreases in intensity of recalls for women with no detected abnormalities. A cost analysis of cytology-only and co-testing strategy was implemented using decision analytic modeling, aggregating testing utilization and costs for each of the two strategies over 12 years. Aggregated incremental costs of the co-testing strategy were positive for the first 3 years but became negative thereafter, generating a cost savings of roughly €20 million in favor of the cytology-only strategy over a 12-year period. Results were robust over a range of sensitivity analyses with respect to discount and attrition rates. This analysis provided valuable information to policy makers contributing to the introduction of co-testing for post-treatment surveillance (PTS) in Ireland.
Irish medical journal, 2007
Timely and convenient access to primary healthcare is essential for the health of the population ... more Timely and convenient access to primary healthcare is essential for the health of the population as delays can incur additional health and financial costs. Access to health care is under increasing scrutiny as part of the drive to contain escalating costs, while attempting to maintain equity in service provision. The objective was to compare primary care services in Republic of Ireland and Northern Ireland, and to report on perceived and reported access to GP services in universal access and mixed private/public systems. A questionnaire study was performed in Northern Ireland (NI) and the Republic of Ireland (ROI). Patients of 20 practices in the ROI and NI were contacted (n = 22,796). Main outcome measures were overall satisfaction and the access to GP services. Individual responses and scale scores were derived using the General Practice Assessment Questionnaire (G-PAQ). The response rate was 52% (n = 11,870). Overall satisfaction with GP practices was higher in ROI than in NI (84...
The British journal of general practice : the journal of the Royal College of General Practitioners, 2002
The recent drive to encourage general practitioners (GPs) to rationalise their prescribing has im... more The recent drive to encourage general practitioners (GPs) to rationalise their prescribing has implications for patients who may have their medication changed. A postal survey of such patients was conducted and it wasfound that 65% were at least reasonably satisfied with the way theyfound out about changes in their medication. Logistic analysis showed that patients were more satisfied when they had been told about the change by a GP or a pharmacist or by a letterfrom the practice.
Social Science & Medicine, 2015
Hastening the death of another whether through assisted suicide or euthanasia is the subject of i... more Hastening the death of another whether through assisted suicide or euthanasia is the subject of intense debate in the UK and elsewhere. In this paper we use a nationally representative survey of public attitudes - the British Social Attitudes survey - to examine changes in attitudes to the legalisation of physician provided euthanasia (PPE) over almost 30 years (1983-2012) and the role of religious beliefs and religiosity in attitudes over time. Compatible questions about attitudes to euthanasia were available in the six years of 1983, 1984, 1989, 1994, 2005, and 2012. We study the trends in the support for legalisation through these time points and the relationship between attitudes, religious denomination and religiosity, controlling for a series of covariates. In total, 8099 individuals provided answers to the question about PPE in the six years of the study. The support for legalisation rose from around 76.95% in 1983 to 83.86% in 2012. This coincided with an increase in secularisation exhibited in the survey: the percentage of people with no religious affiliation increasing from 31% to 45.4% and those who do not attend a religious institution (e.g. church) increasing from 55.7% to 65.03%. The multivariate analysis demonstrates that religious affiliation and religiosity as measured by religious institution attendance frequency are the main contributors to attitudes towards euthanasia, and that the main increase in support happened among the group with least religious affiliation. Other socio-demographic characteristics do not seem to alter these attitudes systematically across the years. Our study demonstrates an increase in the support of euthanasia legalisation in Britain in the last 30 years coincided with increased secularisation. It does not follow, however, that trends in public support are immutable nor that a change in the law would improve on the current pragmatic approach toward hastening death by a physician adopted in England and Wales in terms of the balance between compassion and safeguards against abuse offered.
BMJ open, Jan 3, 2013
To examine the differences in the interval between diagnosis and initiation of treatment among wo... more To examine the differences in the interval between diagnosis and initiation of treatment among women with breast cancer in Northern Ireland. A cross-sectional observational study. All breast cancer care patients in the Northern Ireland Cancer Registry in 2006. All women diagnosed and treated for breast cancer in Northern Ireland in 2006. The number of days between diagnosis and initiation of treatment for breast cancer. The mean (median) interval between diagnosis and initiation of treatment among public patients was 19 (15) compared with 14 (12) among those whose care involved private providers. The differences between individual public providers were as marked as those between the public and private sector-the mean (median) ranging between 14 (12) and 25 (22) days. Multivariate models revealed that the differences were evident when a range of patient characteristics were controlled for including cancer stage. A relatively small number of women received care privately in Northern I...
Histopathology, 2015
Extramammary Paget’s disease, occurring most commonly on the vulva, is an intra-epidermal adenoca... more Extramammary Paget’s disease, occurring most commonly on the vulva, is an intra-epidermal adenocarcinoma in which tumour cells infiltrate the epidermis and sometimes underlying skin appendage structures. The majority of cases of vulval Paget’s disease are primary to that site, probably arising either from primitive epidermal basal cells or adnexal stem cells, and are not associated with an underlying malignancy. However, approximately 5% of cases represent secondary spread from an adenocarcinoma within an internal organ, especially those in which the epithelium is in continuity with the vulva, for example the cervix, colorectum or bladder. Therefore, the possibility of malignancy within an internal organ must always be considered in patients who present with Paget’s disease of the vulva. We report an unusual case of the opposite scenario, whereby a cervical adenocarcinoma developed secondary to retrograde spread of vulval Paget’s disease. We discuss the immunophenotype which, as well as confirming that the cervical adenocarcinoma was secondary to the Paget’s disease, was also potentially misleading, given significant overlap with that expected in a primary cervical adenocarcinoma. A 69-year-old para 3 with a long history of vulval Paget’s disease presented with bladder outflow obstruction which required catheterization. She complained of pelvic discomfort but no vaginal bleeding. Her cervical smear history was normal. The vulval Paget’s disease was first diagnosed on an excision biopsy 14 years previously. She underwent four further vulval excisions during the next 11 years. Each time, the histology was reported as primary vulval Paget’s disease with diffuse positivity of the neoplastic cells with carcinoembryonic antigen (CEA), cytokeratin CAM5.2 and cytokeratin 7 (CK7), focal immunoreactivity with CK20 and negative staining with S100 and HMB45. No dermal invasive component was present. On gynaecological examination, she was found to have a cervical mass and underwent a large loop excision of the transformation zone (LLETZ). The LLETZ biopsy measured 26 9 8 9 7 mm and histological examination showed the tissue to be entirely infiltrated by a poorly differentiated tumour with solid, insular and trabecular growth patterns (Figure 1). There were occasional glandular formations. The tumour cells had abundant eosinophilic cytoplasm and large atypical nuclei with coarse chromatin and visible nucleoli. Mitotic figures were plentiful and areas of necrosis were present. Immunohistochemically, the tumour exhibited diffuse positivity with MNF-116, CK7 and CEA (Figure 2). There was also diffuse (>50%) positivity with p16 and focal immunoreactivity with CK20 while p63, oestrogen receptor (ER), vimentin and S100 were negative. The neuroendocrine markers chromogranin, synaptophysin, CD56 and thyroid transcription factor 1 (TTF1) were also negative. Given the immunophenotype (p16and CEA-positive; ERand vimentin-negative), the features were interpreted as those of a primary cervical adenocarcinoma. The patient was discussed at a gynaecological oncology multidisciplinary team meeting and, given the history of primary vulval Paget’s disease, further immunohistochemistry was performed on the cervical tumour. There was diffuse staining with human epidermal growth factor receptor 2 (HER2)/neu (membranous) and GATA binding protein 3 (GATA3) (nuclear) and focal cytoplasmic positivity with gross cystic dis-
Age and Ageing, 2014
Background: obesity is associated with higher healthcare costs in older people; however, estimate... more Background: obesity is associated with higher healthcare costs in older people; however, estimates are predominantly based on the use of primary and secondary services. Our objective was to estimate the effect of overweight and obesity on the use and cost of allied health services among middle-aged and older people. Methods: the study used data from The Irish Longitudinal Study of Ageing (TILDA), a nationally representative study of adults aged ≥50 sampled using multistage stratified clustered sampling, which included objective measures of height and weight. Body mass index was categorised as normal (18.5-24.99 kg/m 2), overweight (25.00-29.99 kg/m 2), moderate obesity (30.00-34.99 kg/m 2), severe obesity (35.00-39.99 kg/m 2) or morbid obesity (≥40 kg/m 2). Participants were asked about a range of allied health services including dietetic services, public health nurse visits, chiropody and home help. Adjusted seemingly unrelated biprobit models were used to account for unobserved heterogeneity associated with the use of services. Results: among 5,841 participants, 77.6% (95% CI = 76-79%) were overweight or obese (n = 4,534). All classes of obesity were significantly associated with higher general practitioner service use (P < 0.05). Moderate and severe obesity were associated with increased use of outpatient services, while only moderate obesity was associated with increased hospital admissions (P < 0.05). Moderate and severe obesity were significantly associated with chiropody service use (P < 0.05) with an estimated annual cost of €919,662. Morbid obesity was associated with dietetic service use (P < 0.001) with an annual cost of €580,013. Conclusion: given these costs and improvements in life expectancy, an increasingly obese older population presents new challenges for healthcare delivery.
Public Money & Management, 2014
ABSTRACT
In Ireland, over half the adult population are now considered to be overweight or obese. This has... more In Ireland, over half the adult population are now considered to be overweight or obese. This has implications for individuals in terms of their health as well as for the health service in terms of care utilisation. Using SLÁN (2007) data we estimate the impact on use of general practitioner (GP) services, hospital inpatient and hospital day case services of overweight and obesity. Our modelling approach accommodates potential unobserved heterogeneity associated with utilisation of primary and secondary health care. Controlling for a range of sociodemographic variables, we find that overweight and obesity are significant predictors of GP utilisation and obesity is a significant predictor of inpatient episodes. Translating increased utilisation into costs, primary health-care costs are estimated conservatively to be approximately €17 million higher and secondary health-care costs approximately €24 million higher in the Republic of Ireland as a result of overweight and obesity in adul...
PharmacoEconomics, 1998
Objective: The aim of the study was to determine the costs and effects associated with a communit... more Objective: The aim of the study was to determine the costs and effects associated with a community pharmacy-based smoking-cessation programme in Northern Ireland, using the perspective of the payer in the main analysis. Design and setting: Data from a pilot study conducted in 2 community pharmacies in Northern Ireland were used as the basis of the current study, which examined the cost effectiveness of a formal counselling programme for smoking cessation by community pharmacists throughout Northern Ireland. A number of assumptions were made in the baseline analysis (e.g. annual rate of smoking cessation in the absence of the programme; lifetime relapse rate), and these were varied in the sensitivity analysis. Patients and participants: The pilot study upon which the main analysis was based was carried out in 2 Belfast pharmacies over a 2-year period. 52 people entered the smoking-cessation programme (group 1), 48 bought nicotine gum and gave their address so that additional information could be sent and they could be followed-up (group 2), and 60 people who expressed a wish to stop smoking were chosen on the basis that they matched, by age, gender, social status and disease status, those in group 1. Thirty-five of those in group 1 requested to use nicotine gum. A statistically significant difference (p < 0.01) was found in cessation rates between intervention and control patients. Interventions: The Pharmacists Action on Smoking (PAS) model was the only active intervention used in the study. The model was developed by the PAS group in association with the National Pharmaceutical Association (NPA) in the UK in 1994, and was designed specifically for use by community pharmacists to provide advice and motivation to help smokers stop smoking. The 4-stage model involves a written 'contract' between the patient and pharmacist (including a 'stop date'), and a series of brief counselling meetings over a period of approximately 6 months. Main outcome measures and results: Our findings indicate that the cost per life-year saved when using the PAS programme ranges from 196.76 pounds sterling (£) to £351.45 for men and from £181.35 to £772.12 for women (1997 values),
Otology & Neurotology, 2002
To investigate variations in gains in auditory performance in children with cochlear implants. St... more To investigate variations in gains in auditory performance in children with cochlear implants. Study Design: The auditory performance of 98 children was measured with the Category of Auditory Performance survey instrument. All data were collected prospectively. Variables used to explain gain in Category of Auditory Performance were age at implantation, sex, the duration of "untreated" deafness, the year in which implantation occurred, health care inputs, and cause of hearing impairment. The data were analyzed by ordered probabilistic regression analysis. Results: Gain in Category of Auditory Performance was observed to be negatively related to age at implantation, the year in which implantation took place, and the number of medical consultations the child received. None of the other variables were significant determinants of gain in Category of Auditory Performance. Conclusion: This study demonstrates the value of examining incremental gain from implantation rather than simply examining outcome levels. It was found that pediatric implantation is subject to diminishing returns. This suggests that further relaxation of entry criteria to implant programs should be undertaken only after careful consideration. The study also confirmed that age at implantation is an important determinant of outcomes. Greater gain in Category of Auditory Performance was experienced by those who underwent implantation at a younger age. This finding has implications for screening, as well as for purchasers and providers of implant services, highlighting the importance of responding in a timely fashion to identified need.
Medical Care, 2003
BACKGROUND. Recent work has highlighted a negative correlation between proprietary status and nur... more BACKGROUND. Recent work has highlighted a negative correlation between proprietary status and nursing home quality of care. This relationship might be explained by the context in which proprietary homes operate. However, another possible explanation is that some proprietary homes take excessive profit to the detriment of care quality. OBJECTIVE. To examine the relationship between profit levels and quality in proprietary and nonproprietary nursing homes (NHs), accounting for resident and market characteristics. METHODS. Data on 1098 free-standing NHs were taken from the California Office of Statewide Health Planning and Development, the On-line Survey Certification and Reporting System, and California licensing and statistical reports for 1998 and 1999. Tobit multivariate techniques were used to examine the relationship between deficiency citations and a range of explanatory variables, including profit. RESULTS. Proprietary homes in California had significantly lower quality of care than nonproprietary homes. A stratified analysis revealed that, controlling for resident, facility, and market characteristics, profits located within the highest 14% of the proprietary sector's profit distribution were associated with significantly more total deficiencies and serious deficiencies. This relationship was not found in nonproprietary facilities. Other factors related to deficiencies included the ethnic mix of residents and facility size. CONCLUSIONS. Within the context in which proprietary homes operate, profit above a given threshold is associated with a higher number of deficiencies. Given this and the role of the proprietary sector in NH care, careful monitoring of profit levels in this sector appears warranted.
Journal of Public Health, 2000
Background A number of papers have recently been published examining the magnitude of scale econo... more Background A number of papers have recently been published examining the magnitude of scale economies in neonatal care and the level of activity at which these become attainable. Although these agree there is scope for economies in the production of neonatal care, they debate the extent to which such economies are attainable and how they might best be detected. A major multicentre study of neonatal units in the United Kingdom has produced costing and activity data allowing these issues to be explored afresh. Methods A postal questionnaire was used to determine neonatal cost and activity levels in 57 UK neonatal units. Costs for the financial year 1990-1991 related to clinical staffing, support (such as pathology) and overheads (such as heat, light, power and administrative overheads). Activity related to the total number of care days provided and the number of these that were intensive in nature. All data were scrutinized to ensure consistent definitions. A multivariate regression analysis was used to investigate the relationship between costs and activity. Results A double-log function relating variations in total costs to total days, case-mix and an interaction term provided the best fit to the data. The analysis suggests that significant economies of scale are possible within the observed range of provision of intensive care. Conclusions Significant economies of scale may be attainable. Nevertheless, these results should be carefully interpreted. In particular, the costs of neonatal care should not be examined in isolation but in relation to outcomes. In certain instances, units of inefficient scale but acceptable outcome may be defensible on grounds of ease of access.
Journal of Periodontology, 2012
Successful periodontal treatment requires a commitment to regular lifelong maintenance and may be... more Successful periodontal treatment requires a commitment to regular lifelong maintenance and may be perceived by patients to be costly. This study calculates the total lifetime cost of periodontal treatment in the setting of a specialist periodontal practice and investigates the cost implications of choosing not to proceed with such treatment. Data from patients treated in a specialist practice in Norway were used to calculate the total lifetime cost of periodontal treatment that included baseline periodontal treatment, regular maintenance, retreatment, and replacing teeth lost during maintenance. Incremental costs for alternative strategies based on opting to forego periodontal treatment or maintenance and to replace any teeth lost with either bridgework or implants were calculated. Patients who completed baseline periodontal treatment but did not have any additional maintenance or retreatment could replace only three teeth with bridgework or two teeth with implants before the cost of replacing additional teeth would exceed the cost of lifetime periodontal treatment. Patients who did not have any periodontal treatment could replace ≤ 4 teeth with bridgework or implants before a replacement strategy became more expensive. Within the limits of the assumptions made, periodontal treatment in a Norwegian specialist periodontal practice is cost-effective when compared to an approach that relies on opting to replace teeth lost as a result of progressive periodontitis with fixed restorations. In particular, patients who have initial comprehensive periodontal treatment but do not subsequently comply with maintenance could, on average, replace ≤ 3 teeth with bridgework or two teeth with implants before this approach would exceed the direct cost of lifetime periodontal treatment in the setting of the specialist practice studied.
Journal of Epidemiology & Community Health, 1996
Study objective-To investigate the cost effectiveness of personal health education for angina pat... more Study objective-To investigate the cost effectiveness of personal health education for angina patients being treated in general practice.
Journal of Epidemiology & Community Health, 1996
Objective-To establish the effect ofhealth education on the level of distress felt by patients wi... more Objective-To establish the effect ofhealth education on the level of distress felt by patients with angina and to compare the results obtained using different measures. Design-Randomised controlled trial of personal health education given every four months. Setting-Eighteen general practices in the greater Belfast area. Subjects-These comprised 688 patients aged less than 75 years and known to have had angina for at least six months: 342 were randomised to receive education and 346 no education. Main outcome measures-These were the Nottingham health profile (NHP), functional limitation profile (FLP), and a simple categorical scale (SCS). Results-The intervention group showed a statistically significant improvement in health relative to the control group in terms of physical mobility and social isolation using the NHP. In terms of overall wellbeing, both the NHP and SCS results showed the intervention group had experienced statistically significant improvements in health relative to the control group. Results obtained using the NHP, FLP, and SCS were found to be correlated regardless of whether weighted or unweighted scores were used. Conclusion-The intervention produced a significant improvement in health status. Results from different survey instruments were correlated using both weighted and unweighted scores. An SCS was capable of detecting the improvement in health status.
Journal of Agricultural Economics, 1991
... by Clawson (1959), and has been used to value a diverse range of non-market goods, for exampl... more ... by Clawson (1959), and has been used to value a diverse range of non-market goods, for example bird-watching by Harley and Hanley ... to the principles on which the technique is based, there is less agreement as to the precise manner in which the demand relationships should ...
Diabetes Therapy, 2017
Introduction: As part of a control strategy current guidance in the UK recommends more intense su... more Introduction: As part of a control strategy current guidance in the UK recommends more intense surveillance of HbA1C levels among those of Southeast Asian or Chinese ethnicity above specified BMI thresholds. The objective of this study was to determine whether disparities in the identification and control of diabetes in England persisted despite these guidelines and assess current strategies in light of these findings. Methods: Data were extracted from the 2013 Health Survey for England that included ethnicity, BMI status and HbA1C levels. Descriptive statistics and logistic regression analyses were used to examine relationships among undetected diabetes, poorly controlled diabetes and a range of covariates including ethnicity and BMI. Concentration indices were used to examine the socioeconomic gradient in disease detection and control among and between ethnic groups. Results: In regression models that controlled for a range of covariates Asians were found to have a 5% point higher risk of undetected diabetes than Whites. With respect to disease management, Bangladeshis and Pakistanis were found to be at a 28% point and 21% point higher risk of poor disease control respectively than Whites. Concentration indices revealed better disease control among more affluent Whites than poor Whites, no significant pattern between income and disease management was found among Pakistanis and poorer disease control was more evident among more affluent than poorer Bangladeshis. Conclusion: In the UK current guidance recommends practitioners consider testing for diabetes among Southeast Asians and Chinese where BMI exceeds 23. Our findings suggest that the risk experienced by Asians in disease detection is independent of BMI and may warrant a more active screening policy than currently recommended. With respect to disease management, our findings suggest that Indians and Pakistanis experience particularly high levels of poor disease control that may also be usefully reflected in guidance.
BMC pregnancy and childbirth, Jan 24, 2015
There is no consensus on the effect of gestational diabetes mellitus (GDM) on health-related qual... more There is no consensus on the effect of gestational diabetes mellitus (GDM) on health-related quality of life (HRQOL) for the mother in the short or long term. In this study we examined HRQOL in a group of women who had GDM in the index pregnancy 2 to 5 years previously and compared it to a group of women with normal glucose tolerance (NGT) in the index pregnancy during the same time period. The sample included 234 women who met International Association of Diabetes Study Groups (IADPSG) criteria for GDM in the index pregnancy and 108 who had NGT. The sample was drawn from the ATLATIC-DIP (Diabetes In Pregnancy) cohort - a network of antenatal centers along the Irish Atlantic seaboard serving a population of approximately 500,000 people. HRQOL was measured using the visual analogue component of the EQ-5D-3 L instrument in a cross-sectional survey. The difference in HRQOL between GDM and NGT groups was not significant when adjusted for the effects of the covariates. HRQOL was negative...
Expert review of pharmacoeconomics & outcomes research, Jan 17, 2015
Co-testing (cytology plus human papillomavirus DNA testing) as part of cervical cancer surveillan... more Co-testing (cytology plus human papillomavirus DNA testing) as part of cervical cancer surveillance in Ireland increases one-time testing costs. Of interest to policy makers was the long-term impact of these costs accompanied by decreases in intensity of recalls for women with no detected abnormalities. A cost analysis of cytology-only and co-testing strategy was implemented using decision analytic modeling, aggregating testing utilization and costs for each of the two strategies over 12 years. Aggregated incremental costs of the co-testing strategy were positive for the first 3 years but became negative thereafter, generating a cost savings of roughly €20 million in favor of the cytology-only strategy over a 12-year period. Results were robust over a range of sensitivity analyses with respect to discount and attrition rates. This analysis provided valuable information to policy makers contributing to the introduction of co-testing for post-treatment surveillance (PTS) in Ireland.
Irish medical journal, 2007
Timely and convenient access to primary healthcare is essential for the health of the population ... more Timely and convenient access to primary healthcare is essential for the health of the population as delays can incur additional health and financial costs. Access to health care is under increasing scrutiny as part of the drive to contain escalating costs, while attempting to maintain equity in service provision. The objective was to compare primary care services in Republic of Ireland and Northern Ireland, and to report on perceived and reported access to GP services in universal access and mixed private/public systems. A questionnaire study was performed in Northern Ireland (NI) and the Republic of Ireland (ROI). Patients of 20 practices in the ROI and NI were contacted (n = 22,796). Main outcome measures were overall satisfaction and the access to GP services. Individual responses and scale scores were derived using the General Practice Assessment Questionnaire (G-PAQ). The response rate was 52% (n = 11,870). Overall satisfaction with GP practices was higher in ROI than in NI (84...
The British journal of general practice : the journal of the Royal College of General Practitioners, 2002
The recent drive to encourage general practitioners (GPs) to rationalise their prescribing has im... more The recent drive to encourage general practitioners (GPs) to rationalise their prescribing has implications for patients who may have their medication changed. A postal survey of such patients was conducted and it wasfound that 65% were at least reasonably satisfied with the way theyfound out about changes in their medication. Logistic analysis showed that patients were more satisfied when they had been told about the change by a GP or a pharmacist or by a letterfrom the practice.
Social Science & Medicine, 2015
Hastening the death of another whether through assisted suicide or euthanasia is the subject of i... more Hastening the death of another whether through assisted suicide or euthanasia is the subject of intense debate in the UK and elsewhere. In this paper we use a nationally representative survey of public attitudes - the British Social Attitudes survey - to examine changes in attitudes to the legalisation of physician provided euthanasia (PPE) over almost 30 years (1983-2012) and the role of religious beliefs and religiosity in attitudes over time. Compatible questions about attitudes to euthanasia were available in the six years of 1983, 1984, 1989, 1994, 2005, and 2012. We study the trends in the support for legalisation through these time points and the relationship between attitudes, religious denomination and religiosity, controlling for a series of covariates. In total, 8099 individuals provided answers to the question about PPE in the six years of the study. The support for legalisation rose from around 76.95% in 1983 to 83.86% in 2012. This coincided with an increase in secularisation exhibited in the survey: the percentage of people with no religious affiliation increasing from 31% to 45.4% and those who do not attend a religious institution (e.g. church) increasing from 55.7% to 65.03%. The multivariate analysis demonstrates that religious affiliation and religiosity as measured by religious institution attendance frequency are the main contributors to attitudes towards euthanasia, and that the main increase in support happened among the group with least religious affiliation. Other socio-demographic characteristics do not seem to alter these attitudes systematically across the years. Our study demonstrates an increase in the support of euthanasia legalisation in Britain in the last 30 years coincided with increased secularisation. It does not follow, however, that trends in public support are immutable nor that a change in the law would improve on the current pragmatic approach toward hastening death by a physician adopted in England and Wales in terms of the balance between compassion and safeguards against abuse offered.
BMJ open, Jan 3, 2013
To examine the differences in the interval between diagnosis and initiation of treatment among wo... more To examine the differences in the interval between diagnosis and initiation of treatment among women with breast cancer in Northern Ireland. A cross-sectional observational study. All breast cancer care patients in the Northern Ireland Cancer Registry in 2006. All women diagnosed and treated for breast cancer in Northern Ireland in 2006. The number of days between diagnosis and initiation of treatment for breast cancer. The mean (median) interval between diagnosis and initiation of treatment among public patients was 19 (15) compared with 14 (12) among those whose care involved private providers. The differences between individual public providers were as marked as those between the public and private sector-the mean (median) ranging between 14 (12) and 25 (22) days. Multivariate models revealed that the differences were evident when a range of patient characteristics were controlled for including cancer stage. A relatively small number of women received care privately in Northern I...
Histopathology, 2015
Extramammary Paget’s disease, occurring most commonly on the vulva, is an intra-epidermal adenoca... more Extramammary Paget’s disease, occurring most commonly on the vulva, is an intra-epidermal adenocarcinoma in which tumour cells infiltrate the epidermis and sometimes underlying skin appendage structures. The majority of cases of vulval Paget’s disease are primary to that site, probably arising either from primitive epidermal basal cells or adnexal stem cells, and are not associated with an underlying malignancy. However, approximately 5% of cases represent secondary spread from an adenocarcinoma within an internal organ, especially those in which the epithelium is in continuity with the vulva, for example the cervix, colorectum or bladder. Therefore, the possibility of malignancy within an internal organ must always be considered in patients who present with Paget’s disease of the vulva. We report an unusual case of the opposite scenario, whereby a cervical adenocarcinoma developed secondary to retrograde spread of vulval Paget’s disease. We discuss the immunophenotype which, as well as confirming that the cervical adenocarcinoma was secondary to the Paget’s disease, was also potentially misleading, given significant overlap with that expected in a primary cervical adenocarcinoma. A 69-year-old para 3 with a long history of vulval Paget’s disease presented with bladder outflow obstruction which required catheterization. She complained of pelvic discomfort but no vaginal bleeding. Her cervical smear history was normal. The vulval Paget’s disease was first diagnosed on an excision biopsy 14 years previously. She underwent four further vulval excisions during the next 11 years. Each time, the histology was reported as primary vulval Paget’s disease with diffuse positivity of the neoplastic cells with carcinoembryonic antigen (CEA), cytokeratin CAM5.2 and cytokeratin 7 (CK7), focal immunoreactivity with CK20 and negative staining with S100 and HMB45. No dermal invasive component was present. On gynaecological examination, she was found to have a cervical mass and underwent a large loop excision of the transformation zone (LLETZ). The LLETZ biopsy measured 26 9 8 9 7 mm and histological examination showed the tissue to be entirely infiltrated by a poorly differentiated tumour with solid, insular and trabecular growth patterns (Figure 1). There were occasional glandular formations. The tumour cells had abundant eosinophilic cytoplasm and large atypical nuclei with coarse chromatin and visible nucleoli. Mitotic figures were plentiful and areas of necrosis were present. Immunohistochemically, the tumour exhibited diffuse positivity with MNF-116, CK7 and CEA (Figure 2). There was also diffuse (>50%) positivity with p16 and focal immunoreactivity with CK20 while p63, oestrogen receptor (ER), vimentin and S100 were negative. The neuroendocrine markers chromogranin, synaptophysin, CD56 and thyroid transcription factor 1 (TTF1) were also negative. Given the immunophenotype (p16and CEA-positive; ERand vimentin-negative), the features were interpreted as those of a primary cervical adenocarcinoma. The patient was discussed at a gynaecological oncology multidisciplinary team meeting and, given the history of primary vulval Paget’s disease, further immunohistochemistry was performed on the cervical tumour. There was diffuse staining with human epidermal growth factor receptor 2 (HER2)/neu (membranous) and GATA binding protein 3 (GATA3) (nuclear) and focal cytoplasmic positivity with gross cystic dis-
Age and Ageing, 2014
Background: obesity is associated with higher healthcare costs in older people; however, estimate... more Background: obesity is associated with higher healthcare costs in older people; however, estimates are predominantly based on the use of primary and secondary services. Our objective was to estimate the effect of overweight and obesity on the use and cost of allied health services among middle-aged and older people. Methods: the study used data from The Irish Longitudinal Study of Ageing (TILDA), a nationally representative study of adults aged ≥50 sampled using multistage stratified clustered sampling, which included objective measures of height and weight. Body mass index was categorised as normal (18.5-24.99 kg/m 2), overweight (25.00-29.99 kg/m 2), moderate obesity (30.00-34.99 kg/m 2), severe obesity (35.00-39.99 kg/m 2) or morbid obesity (≥40 kg/m 2). Participants were asked about a range of allied health services including dietetic services, public health nurse visits, chiropody and home help. Adjusted seemingly unrelated biprobit models were used to account for unobserved heterogeneity associated with the use of services. Results: among 5,841 participants, 77.6% (95% CI = 76-79%) were overweight or obese (n = 4,534). All classes of obesity were significantly associated with higher general practitioner service use (P < 0.05). Moderate and severe obesity were associated with increased use of outpatient services, while only moderate obesity was associated with increased hospital admissions (P < 0.05). Moderate and severe obesity were significantly associated with chiropody service use (P < 0.05) with an estimated annual cost of €919,662. Morbid obesity was associated with dietetic service use (P < 0.001) with an annual cost of €580,013. Conclusion: given these costs and improvements in life expectancy, an increasingly obese older population presents new challenges for healthcare delivery.
Public Money & Management, 2014
ABSTRACT
In Ireland, over half the adult population are now considered to be overweight or obese. This has... more In Ireland, over half the adult population are now considered to be overweight or obese. This has implications for individuals in terms of their health as well as for the health service in terms of care utilisation. Using SLÁN (2007) data we estimate the impact on use of general practitioner (GP) services, hospital inpatient and hospital day case services of overweight and obesity. Our modelling approach accommodates potential unobserved heterogeneity associated with utilisation of primary and secondary health care. Controlling for a range of sociodemographic variables, we find that overweight and obesity are significant predictors of GP utilisation and obesity is a significant predictor of inpatient episodes. Translating increased utilisation into costs, primary health-care costs are estimated conservatively to be approximately €17 million higher and secondary health-care costs approximately €24 million higher in the Republic of Ireland as a result of overweight and obesity in adul...
PharmacoEconomics, 1998
Objective: The aim of the study was to determine the costs and effects associated with a communit... more Objective: The aim of the study was to determine the costs and effects associated with a community pharmacy-based smoking-cessation programme in Northern Ireland, using the perspective of the payer in the main analysis. Design and setting: Data from a pilot study conducted in 2 community pharmacies in Northern Ireland were used as the basis of the current study, which examined the cost effectiveness of a formal counselling programme for smoking cessation by community pharmacists throughout Northern Ireland. A number of assumptions were made in the baseline analysis (e.g. annual rate of smoking cessation in the absence of the programme; lifetime relapse rate), and these were varied in the sensitivity analysis. Patients and participants: The pilot study upon which the main analysis was based was carried out in 2 Belfast pharmacies over a 2-year period. 52 people entered the smoking-cessation programme (group 1), 48 bought nicotine gum and gave their address so that additional information could be sent and they could be followed-up (group 2), and 60 people who expressed a wish to stop smoking were chosen on the basis that they matched, by age, gender, social status and disease status, those in group 1. Thirty-five of those in group 1 requested to use nicotine gum. A statistically significant difference (p < 0.01) was found in cessation rates between intervention and control patients. Interventions: The Pharmacists Action on Smoking (PAS) model was the only active intervention used in the study. The model was developed by the PAS group in association with the National Pharmaceutical Association (NPA) in the UK in 1994, and was designed specifically for use by community pharmacists to provide advice and motivation to help smokers stop smoking. The 4-stage model involves a written 'contract' between the patient and pharmacist (including a 'stop date'), and a series of brief counselling meetings over a period of approximately 6 months. Main outcome measures and results: Our findings indicate that the cost per life-year saved when using the PAS programme ranges from 196.76 pounds sterling (£) to £351.45 for men and from £181.35 to £772.12 for women (1997 values),
Otology & Neurotology, 2002
To investigate variations in gains in auditory performance in children with cochlear implants. St... more To investigate variations in gains in auditory performance in children with cochlear implants. Study Design: The auditory performance of 98 children was measured with the Category of Auditory Performance survey instrument. All data were collected prospectively. Variables used to explain gain in Category of Auditory Performance were age at implantation, sex, the duration of "untreated" deafness, the year in which implantation occurred, health care inputs, and cause of hearing impairment. The data were analyzed by ordered probabilistic regression analysis. Results: Gain in Category of Auditory Performance was observed to be negatively related to age at implantation, the year in which implantation took place, and the number of medical consultations the child received. None of the other variables were significant determinants of gain in Category of Auditory Performance. Conclusion: This study demonstrates the value of examining incremental gain from implantation rather than simply examining outcome levels. It was found that pediatric implantation is subject to diminishing returns. This suggests that further relaxation of entry criteria to implant programs should be undertaken only after careful consideration. The study also confirmed that age at implantation is an important determinant of outcomes. Greater gain in Category of Auditory Performance was experienced by those who underwent implantation at a younger age. This finding has implications for screening, as well as for purchasers and providers of implant services, highlighting the importance of responding in a timely fashion to identified need.
Medical Care, 2003
BACKGROUND. Recent work has highlighted a negative correlation between proprietary status and nur... more BACKGROUND. Recent work has highlighted a negative correlation between proprietary status and nursing home quality of care. This relationship might be explained by the context in which proprietary homes operate. However, another possible explanation is that some proprietary homes take excessive profit to the detriment of care quality. OBJECTIVE. To examine the relationship between profit levels and quality in proprietary and nonproprietary nursing homes (NHs), accounting for resident and market characteristics. METHODS. Data on 1098 free-standing NHs were taken from the California Office of Statewide Health Planning and Development, the On-line Survey Certification and Reporting System, and California licensing and statistical reports for 1998 and 1999. Tobit multivariate techniques were used to examine the relationship between deficiency citations and a range of explanatory variables, including profit. RESULTS. Proprietary homes in California had significantly lower quality of care than nonproprietary homes. A stratified analysis revealed that, controlling for resident, facility, and market characteristics, profits located within the highest 14% of the proprietary sector's profit distribution were associated with significantly more total deficiencies and serious deficiencies. This relationship was not found in nonproprietary facilities. Other factors related to deficiencies included the ethnic mix of residents and facility size. CONCLUSIONS. Within the context in which proprietary homes operate, profit above a given threshold is associated with a higher number of deficiencies. Given this and the role of the proprietary sector in NH care, careful monitoring of profit levels in this sector appears warranted.
Journal of Public Health, 2000
Background A number of papers have recently been published examining the magnitude of scale econo... more Background A number of papers have recently been published examining the magnitude of scale economies in neonatal care and the level of activity at which these become attainable. Although these agree there is scope for economies in the production of neonatal care, they debate the extent to which such economies are attainable and how they might best be detected. A major multicentre study of neonatal units in the United Kingdom has produced costing and activity data allowing these issues to be explored afresh. Methods A postal questionnaire was used to determine neonatal cost and activity levels in 57 UK neonatal units. Costs for the financial year 1990-1991 related to clinical staffing, support (such as pathology) and overheads (such as heat, light, power and administrative overheads). Activity related to the total number of care days provided and the number of these that were intensive in nature. All data were scrutinized to ensure consistent definitions. A multivariate regression analysis was used to investigate the relationship between costs and activity. Results A double-log function relating variations in total costs to total days, case-mix and an interaction term provided the best fit to the data. The analysis suggests that significant economies of scale are possible within the observed range of provision of intensive care. Conclusions Significant economies of scale may be attainable. Nevertheless, these results should be carefully interpreted. In particular, the costs of neonatal care should not be examined in isolation but in relation to outcomes. In certain instances, units of inefficient scale but acceptable outcome may be defensible on grounds of ease of access.
Journal of Periodontology, 2012
Successful periodontal treatment requires a commitment to regular lifelong maintenance and may be... more Successful periodontal treatment requires a commitment to regular lifelong maintenance and may be perceived by patients to be costly. This study calculates the total lifetime cost of periodontal treatment in the setting of a specialist periodontal practice and investigates the cost implications of choosing not to proceed with such treatment. Data from patients treated in a specialist practice in Norway were used to calculate the total lifetime cost of periodontal treatment that included baseline periodontal treatment, regular maintenance, retreatment, and replacing teeth lost during maintenance. Incremental costs for alternative strategies based on opting to forego periodontal treatment or maintenance and to replace any teeth lost with either bridgework or implants were calculated. Patients who completed baseline periodontal treatment but did not have any additional maintenance or retreatment could replace only three teeth with bridgework or two teeth with implants before the cost of replacing additional teeth would exceed the cost of lifetime periodontal treatment. Patients who did not have any periodontal treatment could replace ≤ 4 teeth with bridgework or implants before a replacement strategy became more expensive. Within the limits of the assumptions made, periodontal treatment in a Norwegian specialist periodontal practice is cost-effective when compared to an approach that relies on opting to replace teeth lost as a result of progressive periodontitis with fixed restorations. In particular, patients who have initial comprehensive periodontal treatment but do not subsequently comply with maintenance could, on average, replace ≤ 3 teeth with bridgework or two teeth with implants before this approach would exceed the direct cost of lifetime periodontal treatment in the setting of the specialist practice studied.
Journal of Epidemiology & Community Health, 1996
Study objective-To investigate the cost effectiveness of personal health education for angina pat... more Study objective-To investigate the cost effectiveness of personal health education for angina patients being treated in general practice.
Journal of Epidemiology & Community Health, 1996
Objective-To establish the effect ofhealth education on the level of distress felt by patients wi... more Objective-To establish the effect ofhealth education on the level of distress felt by patients with angina and to compare the results obtained using different measures. Design-Randomised controlled trial of personal health education given every four months. Setting-Eighteen general practices in the greater Belfast area. Subjects-These comprised 688 patients aged less than 75 years and known to have had angina for at least six months: 342 were randomised to receive education and 346 no education. Main outcome measures-These were the Nottingham health profile (NHP), functional limitation profile (FLP), and a simple categorical scale (SCS). Results-The intervention group showed a statistically significant improvement in health relative to the control group in terms of physical mobility and social isolation using the NHP. In terms of overall wellbeing, both the NHP and SCS results showed the intervention group had experienced statistically significant improvements in health relative to the control group. Results obtained using the NHP, FLP, and SCS were found to be correlated regardless of whether weighted or unweighted scores were used. Conclusion-The intervention produced a significant improvement in health status. Results from different survey instruments were correlated using both weighted and unweighted scores. An SCS was capable of detecting the improvement in health status.
Journal of Agricultural Economics, 1991
... by Clawson (1959), and has been used to value a diverse range of non-market goods, for exampl... more ... by Clawson (1959), and has been used to value a diverse range of non-market goods, for example bird-watching by Harley and Hanley ... to the principles on which the technique is based, there is less agreement as to the precise manner in which the demand relationships should ...