Caring for informal caregivers: policy approaches to the provision of direct support services

Despite being the backbone of modern welfare states, the informal care sector for elderly people in need of long-term care is highly dysfunctional. The majority of informal caregivers are overburdened on account of their care-related activities, although an evolving market for support services directly aimed at relieving informal caregivers is observable. In this paper, we examine the reasons for the imperfect exchange between demand and supply in this market, applying the economic theory of market failure. Through a case study of Austria based on an empirical, qualitative survey of all direct support services and their suppliers on the national level as well as in three provinces, an understanding of this market's main players and mechanisms is derived. Thus, the authors determine that three different system types can be identified beyond the historical regional discrepancies. They illustrate the approaches to service provision for informal caregivers: centralized and public, laissez-faire and private, and a radically decentralized network for informal caregivers. Still, lack of information, social and psychological barriers, as well as high transaction costs, are identified which undermine the support service market for informal care. If the costs of the formal long-term care sector are to be contained despite demographic developments, better policy approaches will be necessary to overcome this challenge. In light of this, recommendations are derived to ensure a better exchange between supply and demand. By providing an initial empirical understanding and analysis of this market and its imperfections, the authors pioneer future quantitative research in this field.     

A Multi-state Piecewise Exponential Model of Hospital Outcomes after Injury

To allow more accurate prediction of hospital length of stay (LOS) after serious injury or illness, a multi-state model is proposed, in which transitions from the hospitalized state to three possible outcome states (home, long-term care, or death) are assumed to follow constant rates for each of a limited number of time periods. This results in a piecewise exponential (PWE) model for each outcome. Transition rates may be affected by time-varying covariates, which can be estimated from a reference database using standard statistical software and Poisson regression. A PWE model combining the three outcomes allows prediction of LOS. Records of 259,941 injured patients from the US Nationwide Inpatient Sample were used to create such a multi-state PWE model with four time periods. Hospital mortality and LOS for patient subgroups were calculated from this model, and time-varying covariate effects were estimated. Early mortality was increased by anatomic injury severity or penetrating mechanism, but these effects diminished with time; age and male sex remained strong predictors of mortality in all time periods. Rates of discharge home decreased steadily with time, while rates of transfer to long-term care peaked at five days. Predicted and observed LOS and mortality were similar for multiple subgroups. Conceptual background and methods of calculation are discussed and demonstrated. Multi-state PWE models may be useful to describe hospital outcomes, especially when many patients are not discharged home.     

A Bayesian compartmental model for the evaluation of 1,3-butadiene metabolism

Summary. We propose a Bayesian model for physiologically based pharmacokinetics of 1,3-butadiene (BD). BD is classified as a suspected human carcinogen and exposure to it is common, especially through cigarette smoke as well as in urban settings. The main aim of the methodology and analysis that are presented here is to quantify variability in the rates of BD metabolism by human subjects. A three-compartmental model is described, together with informative prior distributions for the population parameters, all of which represent real physiological variables. The model is described in detail along with the meanings and interpretations of the associated parameters. A four-compartment model is also given for comparison. Markov chain Monte Carlo methods are described for fitting the model proposed. The model is fitted to toxicokinetic data obtained from 133 healthy subjects (males and females) from the four major racial groups in the USA, with ages ranging from 19 to 62 years. Subjects were exposed to 2 parts per million of BD for 20 min through a face mask by using a computer-controlled exposure and respiratory monitoring system. Stratification by ethnic group results in major changes in the physiological parameters. Sex and age were also tested but not found to have a significant effect.     

The Impact of Socio-economic Status and Mobility on Perceived Family Functioning

Perceptions of current family functioning in relation to current household income level, educational status, social-class at birth and social mobility over the lifecourse were investigated in a group of 483 individuals at age 50. Subjective report of family functioning was assessed using the McMaster Family Assessment Device (FAD) with socio-economic information obtained from a self-report Health and Lifestyle Questionnaire. Results indicated significant relationships between household income, social mobility and FAD scores for men but not for women in this sample. For men, lower current income and downward social mobility over the lifecourse were associated with a more negative perception of family functioning. Further research is required to understand the gender differences observed and delineate cause versus effect mechanisms.