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    ABSTRACT: Quality continues to be placed at the heart of discussions about healthcare. This raises important questions about precisely what quality care is, and how it should be measured. An overall measure of subjective well-being (SWB) that assesses and joins up different stages of the treatment process, and the different people affected, could potentially be used to capture the full impact of quality care throughout the entire treatment process. This article presents a temporal model through which SWB links all stages in the treatment and care process, thus allowing the overall quality of care to be determined and valued according to its direct effect on people's lives. Drawing on existing medical and behavioural studies, we populate this model with evidence that demonstrates how SWB is affected at different points along the patient pathway. SWB is shown to have an effect on outcomes at all stages of the treatment experience and improved health and quality outcomes are shown to consistently enhance SWB. Furthermore, SWB measures are shown to be a suitable method to value the impact of healthcare on the families and carers of patients and, in this way, can join up health outcomes to show wider effects of treatment on patients' lives. Measuring an individual's SWB throughout his or her treatment experience can enable a full appraisal of the quality of care that they receive. This will facilitate service improvements at the micro level and help value treatments for resource allocation purposes at the macro level.
    Social Science [?] Medicine 12/2013; 99:27–34. DOI:10.1016/j.socscimed.2013.09.027

  • BMJ (online) 11/2013; 347:f6716. DOI:10.1136/bmj.f6716
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    ABSTRACT: Poorly performing doctors are a source of harm but do not commonly feature in discussions of patient safety. Few countries have national mechanisms to deal with these doctors; most opt for suspension and/or exclusion from clinical practice. This study reports on the 11-year experience of dealing with concerns about doctors' performance in the UK National Health Service (NHS). The aim of this study was to describe the frequency with which doctors were referred due to performance-related concerns, examine demographic and specialty differences, and identify the nature of the concerns prompting referral. This observational study uses data collected by the National Clinical Assessment Service for each referral (n=6179 doctors) over an 11-year period (April 2001-March 2012) in England to examine the rate at which concerns about doctors' performance occur, understand differences in rates between practitioner groups, and changes over time. The annual referral rate was five per 1000 doctors (95% CI 4.6 to 5.4). Doctors whose first medical qualification was gained outside the UK were more than twice as likely to be referred as UK-qualified doctors; male doctors were more than twice as likely to be referred as women doctors; and doctors in the late stages of their career were nearly six times as likely to be referred as early career doctors. The UK holds a consistently collected national dataset on performance concerns about doctors. This allows risk groups to be identified so that preventive action and early intervention can be targeted most effectively to reduce harm to patients. A feature of past handling of poor clinical performance has been late presentation and a lack of thematic study of causation.
    BMJ quality & safety 10/2013; 23(2). DOI:10.1136/bmjqs-2013-002054

  • The Health service journal 06/2013; 123(6355):20-1.
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    British Journal of Surgery 06/2013; 100(s6):12-13. DOI:10.1002/bjs.9164_5
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    ABSTRACT: Introduction: Open surgery remains the primary technique for resection of pediatric solid tumors despite the popularity of minimally invasive surgery (MIS) for oncological indications in adults and nononcological indications in children. Robot-assisted surgery offers technical and ergonomic advantages that might make MIS more achievable in this setting, permitting benefits for both the patient and surgeon. The aim of this study is to critically appraise the current status of robot-assisted MIS for pediatric solid tumors. Materials and methods: A systematic search of multiple electronic literature databases was undertaken, supplemented by several relevant secondary sources. Results: A total of 23 publications met eligibility criteria, reporting 40 cases overall. Indications for surgery were widely varied, with over 20 different pathologies described. One-third of tumors were classified as malignant. Most procedures involved abdominal or retroperitoneal located tumors in adolescent patients (age range, 1-18 years). The collective complication and conversion rates were 10% and 12.5%, respectively. Oncological adverse events involved two isolated events of tumor spillage and residual disease. The evidence is limited to case reports and small case series only. Conclusions: For the diverse and highly selective cases in this review, robot-assisted MIS seems safe and feasible. Current status is low volume, in a relatively static state of adoption, and without any apparent index pathology or procedure. The benefits of robot assistance seem well suited but remain unsubstantiated by evidence. Higher quality studies are needed to determine true safety and efficacy.
    European Journal of Pediatric Surgery 05/2013; 24(2). DOI:10.1055/s-0033-1347297
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    ABSTRACT: Robotic surgery offers technological solutions to current challenges of minimal access surgery, particularly for delicate and dexterous procedures within spatially constrained operative workspaces in children. The first robotic surgical procedure in a child was reported in April 2001. This review aims to examine the literature for global case volumes, trends, and quality of evidence for the first decade of robotic surgery in children. A systematic literature search was performed for all reported cases of robotic surgery in children during the period of April 2001 to March 2012. Following identification of 220 relevant articles, 137 articles were included, reporting 2393 procedures in 1840 patients. The most prevalent gastrointestinal, genitourinary, and thoracic procedures were fundoplication, pyeloplasty, and lobectomy, respectively. There was a progressive trend of increasing number of publications and case volumes over time. The net overall reported conversion rate was 2.5%. The rate of reported robot malfunctions or failures was 0.5%. Robotic surgery is an expanding and diffusing innovation in pediatric surgery. Future evolution and evaluation should occur simultaneously, such that wider clinical uptake may be led by higher quality and level of evidence literature.
    Journal of Pediatric Surgery 04/2013; 48(4):858-65. DOI:10.1016/j.jpedsurg.2013.01.031
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    ABSTRACT: Almost all health systems seek to offer some form of publicly financed healthcare insurance, and governments must therefore choose the size of the benefit package and the types of treatments to cover. Conventionally, the usual approach of economists has been to recommend choices on the basis of cost effectiveness of treatments, using metrics such as the 'cost per quality adjusted life year'. However, this approach is based on the assumption of health maximization subject to a budget constraint and ignores the potential impact of any additional concern with protecting individuals from the financial consequences of a health shock. Furthermore, it does not take account of the possible availability of complementary privately funded health care. This paper develops a model in which risk-averse individuals care about health but also place a value on protection from the financial consequences of rare but costly events. The paper shows how conventional cost-effectiveness analysis can readily be augmented to take account of financial protection objectives. The results depend on whether or not there exists a market in complementary privately funded health care. They have important implications for the methodology adopted by health technology assessment agencies and for the broader design of publicly funded health systems. Copyright © 2012 John Wiley & Sons, Ltd.
    Health Economics 02/2013; 22(2). DOI:10.1002/hec.2774
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    British Journal of Surgery 01/2013; 100(1). DOI:10.1002/bjs.8972
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    ABSTRACT: Key messages • Technology can improve global health, and includes not only pharmaceuticals, vaccines, and devices, but also advances such as better sanitation and agriculture. • At present, technology for health focuses on the needs of the wealthy. • More frugal technology, specifically designed for the world’s poorest people, is needed. • Such technology also has the potential to be a disruptive technology for health care in high-income countries. • Technology alone is not enough—it needs to be combined with innovations in processes to have the greatest effect. • Capacity to successfully create and use technology should be part of the post-2015 assessment of global development.
    The Lancet 08/2012; 380(9840):507-35. DOI:10.1016/S0140-6736(12)61127-1
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