Smartphone applications: potential tools for use in preparing for CCRN certification examinations.

Recent advances in smartphone technology now allow clinicians to use commercially produced applications when studying for nursing certification examinations. The quality of currently available CCRN review applications varies in this first generation of products. Most are limited to multiple-choice practice questions, although a few have additional elements such as study guides and reference charts. Weaknesses found in the applications evaluated include poorly written and edited content, questions limited to rote memorization rather than application and analysis of knowledge, and content too basic or outside the scope of experienced critical care nursing practice. A list of important factors for consumers to consider before purchase is provided.

Supported employment: cost-effectiveness across six European sites.

A high proportion of people with severe mental health problems are unemployed but would like to work. Individual Placement and Support (IPS) offers a promising approach to establishing people in paid employment. In a randomized controlled trial across six European countries, we investigated the economic case for IPS for people with severe mental health problems compared to standard vocational rehabilitation. Individuals (n=312) were randomized to receive either IPS or standard vocational services and followed for 18 months. Service use and outcome data were collected. Cost-effectiveness analysis was conducted with two primary outcomes: additional days worked in competitive settings and additional percentage of individuals who worked at least 1 day. Analyses distinguished country effects. A partial cost-benefit analysis was also conducted. IPS produced better outcomes than alternative vocational services at lower cost overall to the health and social care systems. This pattern also held in disaggregated analyses for five of the six European sites. The inclusion of imputed values for missing cost data supported these findings. IPS would be viewed as more cost-effective than standard vocational services. Further analysis demonstrated cost-benefit arguments for IPS. Compared to standard vocational rehabilitation services, IPS is, therefore, probably cost-saving and almost certainly more cost-effective as a way to help people with severe mental health problems into competitive employment.

Meeting the challenge of funding and allocating resources to mental health across Europe: developing the Mental Health Economics European Network.

AIMS: There is growing demand for economic analysis to support strategic decision-making for mental health but the availability of economic evidence, in particular on system performance remains limited. The Mental Health Economics European Network (MHEEN) was set up in 2002 with the broad objective of developing a base for mental health economics information and subsequent work in 17 countries. METHODS: Data on financing, expenditure and costs, provision of services, workforce, employment and capacity for economic evaluation were collected through bespoke questionnaires developed iteratively by the Network. This was augmented by a literature review and analysis of international databases. RESULTS: Findings on financing alone suggest that in many European countries mental health appears to be neglected while mechanisms for resource allocation are rarely linked to objective measure of population mental health needs. Numerous economic barriers and potential solutions were identified. Economic incentives may be one way of promoting change, although there is no 'one size fits all solution. CONCLUSIONS: There are significant benefits and synergies to be gained from the continuing development of networks such as MHEEN. In particular the analysis can be used to inform developments in Central and Eastern Europe. For instance there is much that can be learnt on both how the balance of care between institutional and non-institutional care has changed and on the role played by economic incentives in ensuring that resources were used to develop alternative community-based systems.

Economic barriers to better mental health practice and policy.

Mental health systems in many countries are seriously under-developed, yet mental health problems not only have huge consequences for quality of life, but--particularly in low- and middle-income countries--contribute to continued economic burden and reinforce poverty. This paper discusses economic barriers to improving the availability, accessibility, efficiency and equity of mental health care in low- and middle-income countries. Six sets of barriers are identified: an information barrier, resource insufficiency, resource distribution, resource inappropriateness, resource inflexibility and resource timing. Overcoming these barriers will be a major task, although there is no shortage of suggestions for action. The paper discusses broadening the evidence base, improving mental health literacy, tackling stigma, improving financing mechanisms, prioritizing and protecting mental health care budgets, emphasizing mental health promotion through the development of resilience, exploring routes to improved equity, experimenting with new arrangements for purchasing and delivering services, improving coordination between agencies and professionals at both macro- and micro-levels, building alliances between public and private sectors, and training and mobilizing primary care services to improve identification and treatment of mental health problems.

Financing mental health services in low- and middle-income countries.

Mental disorders account for a significant and growing proportion of the global burden of disease and yet remain a low priority for public financing in health systems globally. In many low-income countries, formal mental health services are paid for directly by patients out-of-pocket and in middle-income countries undergoing transition there has been a decline in coverage. The paper explores the impact of health care financing arrangements on the efficient and equitable utilization of mental health services. Through a review of the literature and a number of country case studies, the paper examines the impact of financing mental health services from out-of-pocket payments, private health insurance, social health insurance and taxation. The implications for the development of financing systems in low- and middle-income countries are discussed. International evidence suggests that charging patients for mental health services results in levels of use which are below socially efficient levels as the benefits of the services are distributed according to ability to pay, resulting in inequitable access to care. Private health insurance poses three main problems for mental health service users: exclusion of mental health benefits, limited access to those without employment and refusal to insure pre-existing conditions. Social health insurance may offer protection to those with mental health problems. However, in many low- and middle-income countries, eligibility is based on contributions and limited to those in formal employment (therefore excluding many with mental health problems). Tax-funded systems provide universal coverage in theory. However, the quality and distribution of publicly financed health care services makes access difficult in practice, particularly for rural poor communities.

Adult-to-adult living donor liver transplantation: history, current practice, and implications for the future.

More than 1600 Americans have received adult-to-adult living donor liver transplants. As the number of patients with end-stage liver disease is expected to grow significantly in the next 20 years due to hepatitis C infection, living donor liver transplantation has become a promising solution to the shortage of donor organs. The use of living donors provides organs in an environment of scarcity, allows patients to receive transplants when medically optimized, and produces liver segments with minimal ischemic damage. The donor complications most frequently cited in the medical literature include bile leaks and strictures, biloma, hepatic encephalopathy, wound infection, and pressure sores. In the wake of 2 donor deaths in the United States and subsequent media publicity, there have been new efforts by the transplant community to describe the risks and outcomes for donors, and establish safeguards to protect them from excessive pressure to donate.

Mental health III: funding mental health in Europe

This policy brief provides an overview of the level of funding for mental health in Europe. It looks at the way in which mental health care is financed, and how available funds are distributed within countries in order to facilitate access to a range of services, often provided across a number of sectors such as social care, housing, criminal justice and education. Barriers to increased funding for mental health and to the improved allocation of existing resources are discussed and solutions provided.