Background: This paper presents detailed unit costs for 16 healthcare professionals in community-based non-acute services in Ireland for the years 2016—2019. Unit costs are important data inputs for assessments of health service performance and value for money. Internationally, while some countries have an established database of unit costs for healthcare, there is need for a more coordinated approach to calculating healthcare unit costs. In Ireland, detailed cost analysis of acute care is undertaken by the Healthcare Pricing Office but to date there has been no central database of unit costs for community-based non-acute healthcare services. Methods: Unit costs for publicly employed allied healthcare professionals, Public Health Nurses and Health Care Assistant staff are calculated using a bottom-up micro-costing approach, drawing on methods outlined by the Personal Social Services Research Unit in the UK, and on available Irish and international costing guidelines. Data on salaries, working hours and other parameters are drawn from secondary datasets available from Department of Health, Health Service Executive and other public sources. Unit costs for public and private General Practitioner, dental, and long-term residential care (LTRC) are estimated drawing on available administrative and survey data. Results: The unit costs for the publicly employed non-acute healthcare professionals have changed by 2–6% over the timeframe 2016–2019 while larger percentage changes are observed in the unit costs for public GP visits and public LTRC (14-15%). Conclusions: The costs presented here are a first step towards establishing a central database of unit costs for non-acute healthcare services in Ireland. The database will help ensure consistency across Irish health costing studies and facilitate cross-study and cross-country comparisons. Future work will be required to update and expand on the range of services covered and to incorporate new data and methodological developments in cost estimation as they become available.

Background Globally, there is a rise in chronic disease, including cancer, major organ failure and dementias. Patients and their families in low- and middle-income countries (LMICs) pay a high proportion of medical costs out of pocket (OOP), and a diagnosis of serious illness often has catastrophic financial consequences. We therefore conducted a review of the literature to establish what is known about OOP costs near end of life in LMICs. Aims To identify, organise and report the evidence on out-of-pocket costs in adult end-of-life populations in LMIC. Methods A systematic search of 8 databases and a hand search of relevant systematic reviews and grey literature was performed. Two independent reviewers screened titles and abstracts, assessed papers for eligibility and extracted data. The review was registered with PROSPERO and adhered to the Preferred Reporting items for Systematic Reviews and Meta Analyses. The Mixed Methods Appraisal Tool was used to assess quality. The Wagstaff taxonomy was used to describe OOP. Results After deduplication, 9,343 studies were screened, of which 51 were read and rejected as full texts, and 12 were included in the final review. OOP costs increased with advanced illness and disease severity. The main drivers of OOP were medications and hospitalizations, with high but variable percentages of the affected populations reporting financial catastrophe, lost income, foregone education and other pressures. Conclusion Despite a small number of included studies and heterogeneity in methodology and reporting, it is clear that OOP costs for care near end of life in LMIC represent an important source of catastrophic health expenditures and impoverishment. This suggests a role for widespread, targeted efforts to avoid poverty traps. Financial protection policies for those suffering from incurable disease and future research on the macro- and micro- economics of palliative care delivery in LMIC are greatly needed.

Background Respiratory medicine (RM) and palliative care (PC) physicians’ management of chronic breathlessness in advanced chronic obstructive pulmonary disease (COPD), fibrotic interstitial lung disease (fILD) and lung cancer (LC), and the influence of practice guidelines was explored via an online survey. Methods A voluntary, online survey was distributed to RM and PC physicians via society newsletter mailing lists. Results 450 evaluable questionnaires (348 (77%) RM and 102 (23%) PC) were analysed. Significantly more PC physicians indicated routine use (often/always) of opioids across conditions (COPD: 92% vs. 39%, fILD: 83% vs. 36%, LC: 95% vs. 76%; all p < 0.001) and significantly more PC physicians indicated routine use of benzodiazepines for COPD (33% vs. 10%) and fILD (25% vs. 12%) (both p < 0.001). Significantly more RM physicians reported routine use of a breathlessness score (62% vs. 13%, p < 0.001) and prioritised exercise training/rehabilitation for COPD (49% vs. 7%) and fILD (30% vs. 18%) (both p < 0.001). Overall, 40% of all respondents reported reading non-cancer palliative care guidelines (either carefully or looked at them briefly). Respondents who reported reading these guidelines were more likely to: routinely use a breathlessness score (χ2 = 13.8; p < 0.001), use opioids (χ2 = 12.58, p < 0.001) and refer to pulmonary rehabilitation (χ2 = 6.41, p = 0.011) in COPD; use antidepressants (χ2 = 6.25; p = 0.044) and refer to PC (χ2 = 5.83; p = 0.016) in fILD; and use a handheld fan in COPD (χ2 = 8.75, p = 0.003), fILD (χ2 = 4.85, p = 0.028) and LC (χ2 = 5.63; p = 0.018). Conclusions These findings suggest a need for improved dissemination and uptake of jointly developed breathlessness management guidelines in order to encourage appropriate use of existing, evidence-based therapies. The lack of opioid use by RM, and continued benzodiazepine use in PC, suggest that a wider range of acceptable therapies need to be developed and trialled.

Background End-of-life care attracts major policy interest. Place of death is an important metric of individual experience and health system performance. Most people prefer to die at home, but hospital is the most common place of death in high-income countries. Little is known about international trends in place of death over time. Methods We aimed to collate population-level data on place of death in Europe from 2005 to 2017, and to evaluate association with national characteristics and policy choices. We sought data on hospital as the place of death from the 32 European Economic Area countries. We identified national economic, societal, demographic and health system predictors from Eurostat, OECD and the WHO. We analyzed these cross-national panel data using linear regression with panel-corrected standard errors. Results Our analytic dataset included 30 countries accounting for over 95% of Europe’s population. Average national proportion of deaths occurring in hospital in the study period ranged from 26% to 68%, with a median of 52%. Trends vary markedly by region and wealth, with low and decreasing rate in the North–West, and high and increasing prevalence in the South and East. Controlling for demographic and economic factors, strong palliative care provision and generous government finance of long-term care were associated with fewer hospital deaths. Conclusions We found modifiable policy choices associated with hospital mortality, as well as wider structural economic and societal factors. Policymakers can act to reduce the proportion of dying in hospital.

Background End-of-life care attracts major policy interest. Place of death is an important metric of individual experience and health system performance. Most people prefer to die at home, but hospital is the most common place of death in high-income countries. Little is known about international trends in place of death over time. Methods We aimed to collate population-level data on place of death in Europe for the years 2005-2017, and to evaluate association with national characteristics and policy choices. We sought outcome data from the 32 European Economic Area countries. We identified national economic, societal, demographic and health system predictors from Eurostat, OECD and the WHO. We analysed these cross-national panel data using linear regression with panel-corrected standard errors. Results Our analytic dataset included 30 countries accounting for over 95% of Europe's population and economic activity. Average national proportion of deaths occurring in hospital in the study period ranged from 26% to 68%, with a median of 52%. Trends vary markedly by region and wealth, with low and decreasing hospital deaths in the North-West, and high and increasing prevalence in the South and East. Controlling for demographic and economic factors, strong palliative care provision and generous government finance of long-term care were associated with fewer hospital deaths. Conclusions We found modifiable policy choices associated with hospital mortality, as well as wider structural economic and societal factors. Policymakers can act to curb worrisome trends in-hospital mortality. Data on places of death outside hospital can improve future research, policy and practice. Key messages Cross-national longitudinal analysis. Trends of hospital deaths in Europe, association between hospital mortality rate, palliative care and other healthcare factors.