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    ABSTRACT: Objectives To report findings from a systematic review, this article sought to address two related questions. First, how has the practice of UK pediatric cost-utility analyses evolved over time, in particular how are health-related outcomes assessed and valued? Second, how do the methods compare to the limited guidance available, in particular, the National Institute for Health and Care Excellence (NICE) reference case(s)? Methods Electronic searches of MEDLINE, Embase, and Cochrane databases were conducted for the period May 2004 to April 2012 and the Paediatric Economic Database Evaluation database for the period May 2004 to December 2010. Identified studies were screened by three independent reviewers. Results Forty-three studies were identified, 11 of which elicit utility values through primary research. A discrepancy was identified between the methods used for outcome measurement and valuation and the methods advocated within the NICE reference case. Despite NICE recommending the use of preference-based instruments designed specifically for children, most studies that were identified had used adult measures. In fact, the measurement of quality-adjusted life-years is the aspect of economic evaluation with the greatest amount of variability and the area that most digressed from the NICE reference case. Conclusions Recommendations stemming from the review are that all studies should specify the age range of childhood and include separate statements of perspective for costs and effects as well as the reallocation of research funding away from systematic review studies toward good quality primary research measuring utilities in children.
    Value in Health 06/2014; 17(4). DOI:10.1016/j.jval.2014.02.007
  • The Journal of urology 03/2014; DOI:10.1016/j.juro.2014.01.011
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    ABSTRACT: To undertake a cost effectiveness analysis comparing conservative management, surgery, and radiosurgery for treating small-to-medium (1-20mm) sized vestibular schwannomas. Model based economic evaluation using individual-level data from a Birmingham-based longitudinal patient database, and from published sources. Both a decision-tree and state transition (Markov) model were developed, from a NHS (National Health Service) perspective. Sensitivity analyses were also carried out. Secondary care treatment for patients with small-to-medium sized vestibular schwannomas. Three hypothetical cohorts of adult patients receiving either conservative management, radiosurgery or surgery treatment, aged 58 years as starting age within model. Cost-effectiveness based on cost per quality-adjusted life year (QALY). Conservative management is the preferred strategy for the treatment of small-to-medium sized vestibular schwannomas. Conservative management is both cheaper (-£722 and -£2,764) and more effective (0.136 and 0.554 QALYs) than both radiosurgery and surgery respectively. A conservative strategy can therefore be considered as highly cost effective. This result is sensitive to the assumed quality of life parameters in the model. Sensitivity analysis suggests that the probability of a conservative strategy being the most cost-effective approach compared to surgery and radiosurgery at a willingness to pay of £20,000/QALY gained, is 80% and 55% respectively. A conservative approach is the preferred strategy for treatment of small-to-medium vestibular schwannomas. This result is sensitive to quality of life values used in the analysis. More research is required to assess the impact of treatment upon patients' health-related quality of life over time. This article is protected by copyright. All rights reserved.
    Clinical otolaryngology: official journal of ENT-UK; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery 12/2013; 39(1). DOI:10.1111/coa.12205
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    ABSTRACT: Evidence is emerging that rates of adverse events in patients taking warfarin may vary with ethnicity. This study investigated the rates of bleeds and thromboembolic events, the international normalised ratio (INR) status and the relationship between INR and bleeding events in Malaysia. Patients attending INR clinic at the Heart Centre, Sarawak General Hospital were enrolled on an ad hoc basis from May 2010 and followed up for 1 year. At each routine visit, INR was recorded and screening for bleeding or thromboembolism occurred. Variables relating to INR control were used as predictors of bleeds in logistic regression models. 125 patients contributed to 140 person-years of follow-up. The rates of major bleed, thromboembolic event and minor bleed per 100 person-years of follow-up were 1.4, 0.75 and 34.3. The median time at target range calculated using the Rosendaal method was 61.6 % (IQR 44.6-74.1 %). Of the out-of-range readings, 30.0 % were below range and 15.4 % were above. INR variability, (standard deviation of individuals' mean INR), was the best predictor of bleeding events, with an odds ratio of 3.21 (95 % CI 1.10-9.38). Low rates of both major bleeds and thromboembolic events were recorded, in addition to a substantial number of INR readings under the recommended target range. This may suggest that the recommended INR ranges may not represent the optimal warfarin intensity for this population and that a lower intensity of therapy, as observed in this cohort, could be beneficial in preventing adverse events.
    Journal of Thrombosis and Thrombolysis 11/2013; 38(2). DOI:10.1007/s11239-013-1017-6
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    ABSTRACT: The preferences of informal carers are important to capture for healthcare decision making. This paper discusses how these preferences relate to the economic evaluation of health and care interventions. Three main issues are highlighted. First, there is a need to consider carer impact routinely in economic evaluations. Second, more debate is required around the ethical issues stemming from the inclusion of interdependent preferences in healthcare decision making. Third, there are a number of situations where carer and patient preferences may conflict and practical ways of representing and handling these conflicts would be useful.
    The patient 11/2013; 6(4). DOI:10.1007/s40271-013-0035-y
  • Journal of the Royal Society of Medicine 10/2013; 107(2). DOI:10.1177/0141076813507707
  • BMJ (online) 10/2013; 347:f5932. DOI:10.1136/bmj.f5932
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    ABSTRACT: To examine the current approach to leadership development in the English National Health Service (NHS) and consider its implications for nursing. To stimulate debate about the nature of leadership development in a range of health care settings. Good leadership is central to the provision of high quality nursing care. This has focussed attention on the leadership development of nurses and other health care staff. It has been a key policy concern in the English NHS of late and fostered the growth of leadership development programmes founded on competency based approaches. This is a policy review informed by the concept of episteme. Relevant policy documents and related literature. Using Foucault's concept of episteme, leadership development policy is examined in context and a 'counter narrative' developed to demonstrate that current approaches are rooted in competency based accounts which constitute a limited, yet dominant narrative. Leadership takes many forms and varies hugely according to task and context. Acknowledging this in the form of a counter narrative offers a contribution to more constructive policy development in the English NHS and more widely. A more nuanced debate about leadership development and greater diversity in the provision of development programmes and activities is required. Leadership development has been advocated as being crucial to the advancement of nursing. Detailed analysis of its nature and function is essential if it is to meet the needs of nurse leaders.
    International journal of nursing studies 09/2013; DOI:10.1016/j.ijnurstu.2013.08.004
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    ABSTRACT: Abstract This paper reports on the process and outcomes of a study, designed to pilot the use of interprofessional, simulation-based training in end of life care communication. Participants comprised 50 final year medicine, nursing, physiotherapy and pharmacy students. Learning methods included observation of role play and facilitated, interactive group discussion. A Likert scale rating questionnaire was used to evaluate the impact of the learning experience. Evaluation data revealed that students were supportive of interprofessional learning and could recognise its benefits. The results indicated self-perceived improvements in knowledge, skills, confidence and competence when dealing with challenging end of life care communication situations. Comparison of pre- and post-intervention scores revealed a statistically significant positive change in the students' perceptions about their level of knowledge (Z = -5.887, p = 0.000). The reported benefits need to be balanced against design and delivery issues that proved labour and resource intensive. Economic evaluation is worthy of further consideration.
    Journal of Interprofessional Care 08/2013; 28(1). DOI:10.3109/13561820.2013.827163
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    ABSTRACT: We describe methods for meta-analysis of randomised trials where a continuous outcome is of interest, such as blood pressure, recorded at both baseline (pre treatment) and follow-up (post treatment). We used four examples for illustration, covering situations with and without individual participant data (IPD) and with and without baseline imbalance between treatment groups in each trial. Given IPD, meta-analysts can choose to synthesise treatment effect estimates derived using analysis of covariance (ANCOVA), a regression of just final scores, or a regression of the change scores. When there is baseline balance in each trial, treatment effect estimates derived using ANCOVA are more precise and thus preferred. However, we show that meta-analysis results for the summary treatment effect are similar regardless of the approach taken. Thus, without IPD, if trials are balanced, reviewers can happily utilise treatment effect estimates derived from any of the approaches. However, when some trials have baseline imbalance, meta-analysts should use treatment effect estimates derived from ANCOVA, as this adjusts for imbalance and accounts for the correlation between baseline and follow-up; we show that the other approaches can give substantially different meta-analysis results. Without IPD and with unavailable ANCOVA estimates, reviewers should limit meta-analyses to those trials with baseline balance. Trowman's method to adjust for baseline imbalance without IPD performs poorly in our examples and so is not recommended. Finally, we extend the ANCOVA model to estimate the interaction between treatment effect and baseline values and compare options for estimating this interaction given only aggregate data. Copyright © 2013 John Wiley & Sons, Ltd.
    Statistics in Medicine 07/2013; 32(16). DOI:10.1002/sim.5726
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