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ABSTRACT: The use of patient reported outcome measures within cost-effectiveness analysis has become commonplace. However, specific measures are required that produce values, referred to as 'utilities', that are capable of generating quality adjusted life years. One such measure - the EQ-5D - has come under criticism due to the inherent limitations of its three-level response scales. In evaluations of chronic pain, the numerical pain rating scale (NPRS) which has eleven levels is routinely used which has a greater measurement range, but which can not be used in cost-effetiveness analyses. This study derived utility values for a series of EQ-5D health states that replace the pain dimensions with the NPRS, thereby allowing a potentially greater range of pain intensities to be captured and included in economic analyses.
Interviews were undertaken with 100 member of the general population. Health state valuations were elicited using the time trade-off approach with a ten year time horizon. Additionally, respondents were asked where the EQ-5D response scale descriptors of moderate and extreme pain lay on the 11-point NPRS scale.
625 valuations were undertaken across the study sample with the crude mean health state utilities showing a negative non-linear relationship with respect to increasing pain intensity. Relative to a NPRS of zero (NPRS0), the successive pain levels (NPRS1-10) had mean decrements in utility of 0.034, 0.043, 0.061, 0.121, 0.144, 0.252, 0.404, 0.575, 0.771 and 0.793, respectively. When respondents were asked to mark on the NPRS scale the EQ-5D pain descriptors of moderate and extreme pain, the median responses were '4' and '8', respectively.
These results demonstrate the potential floor effect of the EQ-5D with respect to pain and provide estimates of health reduction associated with pain intensity described by the NPRS. These estimates are in excess of the decrements produced by an application of the EQ-5D scoring tariff for both the United States and the United Kingdom.
Health and Quality of Life Outcomes 11/2011; 9:96. · 2.11 Impact Factor
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ABSTRACT: Despite the increase in the number of inherited metabolic diseases that can be detected at birth using a single dried blood spot sample, the impact of false positive results on parents remains a concern. We used an economic approach - the contingent valuation method - which asks parents to give their maximum willingness to pay for an extension in a screening programme and the degree to which the potential for false positive results diminishes their valuations. 160 parents of a child or children under the age of 16 years were surveyed and given descriptions of the current screening programme in the UK, an extended programme and an extended programme with no false positives. 148 (92.5%) respondents said they would accept the screen for the five extra conditions in an expanded screening programme whilst 10 (6.3%) said they would not and two were unsure. When asked to indicate if they would choose to be screened under an expanded screening programme with no false positive results, 152 (95%) said they would, five (3.1%) said they would not, two were unsure, and there was one non-response. 151 (94.4%) said they preferred the hypothetical test with no false-positives. The mean willingness to pay for the expanded programme was £178 compared to £219 for the hypothetical expanded programme without false positives (p > 0.05). The results suggest that there is widespread parental support for extended screening in the UK and that the number of false-positives is a relatively small issue.
Journal of Inherited Metabolic Disease 05/2011; 35(1):169-76. · 3.58 Impact Factor
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ABSTRACT: Chest pain due to suspected myocardial infarction (MI) is responsible for many hospital admissions and consumes substantial health care resources. The Randomized Assessment of Treatment using Panel Assay of Cardiac markers (RATPAC) trial showed that diagnostic assessment using a point-of-care (POC) cardiac biomarker panel consisting of CK-MB, myoglobin, and troponin increased the proportion of patients successfully discharged after emergency department (ED) assessment. In this economic analysis, the authors aimed to determine whether POC biomarker panel assessment reduced health care costs and was likely to be cost-effective.
The RATPAC trial was a multicenter individual patient randomized controlled trial comparing diagnostic assessment using a POC biomarker panel (CK-MB, myoglobin, and troponin, measured at baseline and 90 minutes) to standard care without the POC panel in patients attending six EDs with acute chest pain due to suspected MI (n = 2,243). Individual patient resource use data were collected from all participants up to 3 months after hospital attendance using self-completed questionnaires at 1 and 3 months and case note review. ED staff and POC testing costs were estimated through a microcosting study of 246 participants. Resource use was valued using national unit costs. Health utility was measured using the EQ-5D self-completed questionnaire, mailed at 1 and 3 months. Quality-adjusted life-years (QALYs) were calculated by the trapezium rule using the EQ-5D tariff values at all follow-up points. Mean costs per patient were compared between the two treatment groups. Cost-effectiveness was estimated in terms of probability of dominance and incremental cost per QALY.
Point-of-care panel assessment was associated with higher ED costs, coronary care costs, and cardiac intervention costs, but lower general inpatient costs. Mean costs per patient were £1217.14 (standard deviation [SD] ± 3164.93), or $1,987.14 (SD ±$4,939.25), with POC versus £1005.91 (SD ±£1907.55), or $1,568.64 (SD ±$2,975.78), with standard care (p = 0.056). Mean QALYs were 0.158 (SD ± 0.052) versus 0.161 (SD ± 0.056; p = 0.250). The probability of standard care being dominant (i.e., cheaper and more effective) was 0.888, while the probability of the POC panel being dominant was 0.004. These probabilities were not markedly altered by sensitivity analysis varying the costs of the POC panel and excluding intensive care costs.
Point-of-care panel assessment does not reduce costs despite reducing admissions and may even increase costs. It is unlikely to be considered a cost-effective use of health care resources.
Academic Emergency Medicine 05/2011; 18(5):488-95. · 1.86 Impact Factor
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ABSTRACT: The aim of this study was to measure health utility and survival in patients with acute cardiogenic pulmonary oedema (ACPO), identify predictors of outcome and determine the effect of initial treatment with non-invasive ventilation (NIV) upon outcomes.
A randomised controlled trial was conducted at 26 hospitals in the UK. 1069 adults with ACPO were randomised to continuous positive airway pressure (CPAP), non-invasive positive pressure ventilation (NIPPV) or standard oxygen therapy. The main outcome measures were survival to 1-5 years, health utility measured using the EQ-5D survey at 1, 3 and 6 months, and quality-adjusted life years (QALYs).
Median survival was 771 days (95% CI 669 to 875), with no difference between the three treatment groups (p = 0.827). Age (HR 1.042, 95% CI 1.031 to 1.052), chronic obstructive pulmonary disease (HR 1.13, 95% CI 1.06 to 1.62), cerebrovascular disease (HR 1.41, 95% CI 1.14 to 1.73) and diabetes mellitus (HR 1.31, 95% CI 1.01 to 1.63) independently predicted mortality. Mean EQ-5D scores were 0.578, 0.576 and 0.582 at 1, 3 and 6 months, respectively, with no significant difference between the treatment groups. Male gender (+0.045 QALYs, 95% CI 0.009 to 0.081) and cerebrovascular disease (-0.080 QALYs, 95% CI -0.131 to -0.029) independently predicted health utility.
Patients with ACPO have high mortality and reduced health utility. Initial treatment with CPAP or NIPPV does not alter subsequent survival or health utility.
Emergency Medicine Journal 10/2010; 28(6):477-82. · 1.44 Impact Factor
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ABSTRACT: This paper reviews the role of patient preferences within the framework of cost-effectiveness analysis (CEA). CEA typically adopts a system-wide perspective by focusing upon efficiency across groups in the allocation of scarce healthcare resources, whereas treatment decisions are made over individuals. However, patient preferences have been shown to have a direct impact on the outcome of an intervention via psychological factors or indirectly via patient adherence/compliance rates. Patient values may also be in conflict with the results of CEA through the valuation of benefits. CEA relies heavily on the QALY model to reflect individual preferences, although the healthy year equivalent offers an alternative measure that may be better at taking individual preferences into account. However, both measures typically use mean general population or mean patient values and therefore create conflict with individual-level preferences. For CEA to reflect practice, it must take into account the impact of individual patient preferences even where general population preferences are used to value the benefits of interventions. Patient preferences have implications for cost effectiveness through costs and outcomes, and it is important that cost-effectiveness models incorporate these through its structure (e.g. allowing for differing compliance rates) and parameter values, including clinical effectiveness. It will also be necessary to try to predict patient preferences in order to estimate any impact on cost effectiveness through analyses of revealed and stated preference data. It is recognized that policy makers are concerned with making interventions available to patients and not forcing them to consume healthcare. One way of moving towards this would be to adopt a two-part decision process: the identification of the most cost-effective therapy using mean general population values (i.e. the current rule), then also making available those treatments that are cheaper than the most cost-effective therapy.
PharmacoEconomics 01/2009; 27(9):705-12. · 2.66 Impact Factor
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ABSTRACT: To evaluate benefits for postnatal women of two psychologically informed interventions by health visitors.
Prospective cluster trial randomised by general practice, with 18 month follow-up.
101 general practices in Trent, England.
2749 women allocated to intervention, 1335 to control.
Health visitors (n=89 63 clusters) were trained to identify depressive symptoms at six to eight weeks postnatally using the Edinburgh postnatal depression scale (EPDS) and clinical assessment and also trained in providing psychologically informed sessions based on cognitive behavioural or person centred principles for an hour a week for eight weeks. Health visitors in the control group (n=49 38 clusters) provided usual care.
Score >or=12 on the Edinburgh postnatal depression scale at six months. Secondary outcomes were mean Edinburgh postnatal depression scale, clinical outcomes in routine evaluation-outcome measure (CORE-OM), state-trait anxiety inventory (STAI), SF-12, and parenting stress index short form (PSI-SF) scores at six, 12, 18 months.
4084 eligible women consented and 595 women had a six week EPDS score >or=12. Of these, 418 had EPDS scores available at six weeks and six months. At six months, 34% women (93/271) in the intervention group and 46% (67/147) in the control group had an EPDS score >or=12. The odds ratio for score >or=12 at six months was 0.62 (95% confidence interval 0.40 to 0.97, P=0.036) for women in the intervention group compared with women in the control group. After adjustment for covariates, the odds ratio was 0.60 (0.38 to 0.95, P=0.028). At six months, 12.4% (234/1880) of all women in the intervention group and 16.7% (166/995) of all women in the control group had scores >or=12 (0.67, 0.51 to 0.87, P=0.003). Benefit for women in the intervention group with a six week EPDS score >or=12 and for all women was maintained at 12 months postnatally. There was no differential benefit for either psychological approach over the other.
Training health visitors to assess women, identify symptoms of postnatal depression, and deliver psychologically informed sessions was clinically effective at six and 12 months postnatally compared with usual care.
ISRCTN92195776.
BMJ (Clinical research ed.). 01/2009; 338:a3045.
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ABSTRACT: To evaluate the benefits of paramedic practitioners assessing and, when possible, treating older people in the community after minor injury or illness. Paramedic practitioners have been trained with extended skills to assess, treat, and discharge older patients with minor acute conditions in the community.
Cluster randomised controlled trial involving 56 clusters. Weeks were randomised to the paramedic practitioner service being active (intervention) or inactive (control) when the standard 999 service was available.
A large urban area in England.
3018 patients aged over 60 who called the emergency services (n=1549 intervention, n=1469 control).
Emergency department attendance or hospital admission between 0 and 28 days; interval from time of call to time of discharge; patients' satisfaction with the service received.
Overall, patients in the intervention group were less likely to attend an emergency department (relative risk 0.72, 95% confidence interval 0.68 to 0.75) or require hospital admission within 28 days (0.87, 0.81 to 0.94) and experienced a shorter total episode time (235 v 278 minutes, 95% confidence interval for difference -60 minutes to -25 minutes). Patients in the intervention group were more likely to report being highly satisfied with their healthcare episode (relative risk 1.16, 1.09 to 1.23). There was no significant difference in 28 day mortality (0.87, 0.63 to 1.21).
Paramedics with extended skills can provide a clinically effective alternative to standard ambulance transfer and treatment in an emergency department for elderly patients with acute minor conditions.
ISRCTN27796329 [controlled-trials.com].
BMJ (Clinical research ed.). 12/2007; 335(7626):919.
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ABSTRACT: This journal supplement publishes four original studies that report the evaluation of a basal insulin analogue – glargine – for the treatment of type 1 and type 2 diabetes. Two of the studies present economic models that use data from the original randomised controlled trials (RCTs) of glargine versus neutral protamine Hagedorn insulin (NPH) and new evidence on the impact of fear of hypoglycaemia on health utility. Their findings suggest that glargine is cost-effective in both type 1 and type 2 diabetes, not just in type 1 as concluded by the original economic appraisal of glargine by NICE in 2002. The remaining two studies use ‘real-life’ data from a proprietary general practice database in the UK (The Health Improvement Network (THIN)) to determine the financial costs and outcomes of glargine treatment compared to treatment with insulin detemir (detemir). Their findings draw attention to the issue that pivotal clinical trials designed specifically to show non-inferiority with the comparator insulin, may not show the true value of glargine which was found to be less costly and resulted in improved outcomes in real-life use than detemir. Observational data are a vital component of drug evaluation and a reliable picture of the financial and clinical outcome can only be drawn following a thorough review of observational data in addition to clinical trial data. Viewed together, these studies are examples of how the current system of economic appraisal of health technology and its dogmatic reliance on RCT evidence may not be in the best interests of patients.
02/2007; 23(s1):S1-S6.
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ABSTRACT: Advanced access has been forwarded as a strategy for reducing waiting times in primary care; however, previous evaluations have raised important issues regarding its appropriateness.
The objectives of this paper are to assess the impact of advanced access on patient access to primary care services, and its broader effects on stakeholders.
A quantitative analysis of appointment data on 462 practices implementing advanced access, together with qualitative analysis of open survey responses and interviews with 28 practice staff. Appointment data recorded time to third available appointment for GP and practice nurse, together with the percentage of patients seen on their day of choice. Themes were identified from the interviews and survey responses and related to issues identified in previous research.
The implementation of advanced access was associated with reductions in time to see practice nurses as well as GPs, and increases in the proportion of patients being seen on their day of choice. Interviewee and survey responses suggested that practice population characteristics may impact on the model, and some patient groups may be disadvantaged from the changes in the appointment systems seen in this study. Whilst experiences were mixed, the potential for broader changes to working practices of all practice staff was evident.
In general, these results suggest that advanced access can have a positive impact across several aspects of primary care services, and not just the availability of GP appointments. However, it also highlights some problems, in that waiting times worsened in some practices and there were concerns that some vulnerable groups may be disadvantaged.
Family Practice 05/2006; 23(2):233-9. · 1.50 Impact Factor
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ABSTRACT: Immunosuppressive therapy is required to prevent graft rejection. Calcineurin inhibitors such as tacrolimus are paradoxically toxic to the kidney, whereas sirolimus (rapamycin; Rapamune) is not generally associated with the nephrotoxicity of CNIs. The purpose of this study was to evaluate the relative cost utility of sirolimus versus tacrolimus for the primary prevention of graft rejection in renal transplant recipients in the UK.
A stochastic simulation model was constructed using clinical trial and observational data comparing the two treatments. Time duration was up to 20 years. Costs were from a UK NHS perspective, valued at 2003 prices and discounted at 6%. Benefits were discounted at 1.5%. Simulated events included patient and graft survival, haemodialysis, peritoneal dialysis, re-transplants and acute rejection. Costs were summed for events and various maintenance therapies. Utility was differentially accredited depending upon survival and using the alternative renal replacement therapies. Outcome was predicted using post-transplant creatinine levels up to 3 years. Extensive statistical economic and sensitivity analyses were undertaken.
Over the 10-year horizon, sirolimus gained 0.72 years (discounted) of functioning graft over tacrolimus, resulting in an incremental cost per year of functioning graft that was dominant. Over a 20-year time horizon, the cost effectiveness of sirolimus over tacrolimus further improved with an average discounted gain in years of a functioning graft of 1.8 years, resulting in an incremental cost-utility ratio that was also dominant. The number of haemodialysis events was 48,243 for sirolimus recipients versus 127,829 for those receiving tacrolimus and peritoneal dialysis events 40,872 versus 105,249, respectively. Similar values were obtained when real-life observational data on tacrolimus use in Cardiff, Wales were entered into the model. Using data from Cardiff, sirolimus remained dominant over tacrolimus under all scenarios.
Our study suggests that sirolimus may be more cost effective than tacrolimus for the primary prevention of graft rejection in renal transplant recipients in the UK. Sirolimus was economically 'dominant' under almost all scenarios investigated. This finding was robust using statistical economic analysis and univariate sensitivity analysis.
PharmacoEconomics 02/2006; 24(1):67-79. · 2.66 Impact Factor
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ABSTRACT: Results were combined from representative surveys of health related quality of life (HRQoL; n=11,877; age range=16-104) with data from a randomized controlled trial of cognitive behavior therapy for chronic insomnia (n=209; age range=31-92). Secondary analyses of scores from the SF-36 measure of HRQoL were conducted in order: (a) to compare the health related quality of life profiles of adult hypnotic users with chronic insomnia with those of population norms, and (b) to assess the impact of cognitive behavior therapy (CBT) for insomnia on HRQoL outcomes over 6 months. Compared with the primary care reference values, HRQoL among the trial participants at baseline was generally poorer. The magnitude of these decrements reduced markedly with advancing age. In the evaluation of the CBT intervention, statistically significant differences in SF-36 scores in favor of the intervention were present for physical functioning, emotional role limitation, and mental health over 6 months. Overall, this study shows that the SF-36 can play an important role in describing HRQoL in this patient group, and in the evaluation of interventions within this group.
Behavioral Sleep Medicine 02/2006; 4(2):71-84. · 1.55 Impact Factor
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ABSTRACT: Despite great interest in the development of methods used in the economic evaluation of health technologies, the effects of carer costs and quality of life (QOL) on the cost effectiveness of treatments has not been widely explored. Yet carer effects are clearly evident in the literature and relevant to the perspective of many published economic evaluations.
To examine whether patient QOL is associated with carer time and carer QOL.
We used two datasets to investigate carer effects. Firstly, we used 40,312 cases from the Health Outcomes Data Repository (HODaR) to assess the relationship between patient utility, using the EuroQoL (EQ)-5D, and the number of days care needed from friends and relatives. The stability of the relationship across patient subgroups was assessed by replicating the analysis in ten disease groups. Secondly, we used 64 cases from a study of patients with Alzheimer's disease and their primary carer. These data allowed us to estimate the relationships between patient and carer utility, using the EQ-5D, and patient utility and carer burden using the Community Dementia Quality of Life Profile (CDQLP).
For carer time, a linear model showed that each 0.1-point reduction in patient utility was associated with a 2.5-day increase in carer time over a 6-week period. A more general model, based on EQ-5D domain scores, was better specified and showed that decreased functioning within each domain is associated with increased carer time. Problems with self-care and usual activities have the greatest impact on carer time. These models do not appear to be stable across different disease groups. For carer utility, the relationships between carer and patient utility have low explanatory power and are poorly specified. A clearer relationship is shown between carer burden and utility, such that when sociodemographic covariates are introduced, the relationship reaches conventional levels of statistical significance (p < 0.05).
The preliminary work described here shows that improving patient QOL may reduce the need for carer time and improve carer QOL. Incorporating such effects into economic evaluations will change cost-per-QALY estimates, with the size of reduction dependent on the domains of health affected by treatment. Clinical studies need to capture carer data so that we can better understand these effects, and how they impact on economic evaluation.
PharmacoEconomics 01/2006; 24(1):43-53. · 2.66 Impact Factor
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ABSTRACT: The pattern of renal transplantation has never been described since the introduction of the technique. The purpose of this study was therefore to characterise the pattern of renal transplantation from 1967 to 2000, focusing on renal graft function as a predictor of survival.
This study was a retrospective analysis of an electronic database. The setting was a single renal transplant centre in the United Kingdom covering a population of 2.2 million and included patients who received at least one renal transplant over the study period (n = 1516). The main outcome measures were patient and graft survival, acute rejection episodes and patterns of graft function, as measure by creatinine levels.
There were 559 (36.8%) female patients; 109 (7.2%) patients had pre-existing diabetes. Patient survival was adversely affected by increased age at transplant (p < 0.001): 5-year patient survival from first transplant was 82% for patients aged 0 to 17 years, 80% for 18 to 49 years and 61% for > 49 years. Pre-existing diabetes also adversely affected survival (p < 0.01): 5-year graft survival was 63% for patients with diabetes versus 74% for those without. Graft survival was significantly associated with serum creatinine levels recorded 1 year post-primary transplant (p < 0.001) and with three or more acute rejection episodes (p < 0.05). Neither gender nor diabetes status were statistically significant in predicting graft survival. The number of acute rejection episodes was significantly greater in patients with pre-existing diabetes than those without (61% versus 42%, respectively; p < 0.001). There were no differences in the number of acute rejection episodes occurring across age groups.
Patient and graft survival improved markedly over the 34-year study period, although patient survival has changed little since 1990. Serum creatinine levels are a reliable predictor of graft survival.
Current Medical Research and Opinion 11/2005; 21(11):1793-800. · 2.38 Impact Factor
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ABSTRACT: To evaluate the impact on hospital costs of patients being diagnosed with multiple complications of diabetes.
All inpatient admissions and outpatient appointments from the Cardiff and Vale of Glamorgan area (1996 onwards) were cross-referenced to the diabetes register. Each episode of inpatient care was coded using Healthcare Resource Group (HRG) grouper software. The allocated HRG-coded episode was linked to a series of elective and emergency reference costs from the National Health Service costing manual. Outpatient appointments were cost-coded using the mean reference costs by specialty. Non-psychiatric finished consultant episodes (FCEs) were used rather than admissions to report inpatient utilisation.
Overall, 2815 of the total 10,287 patients identified as inpatients had at least one admission; 6133 admissions (finished consultant episodes) were successfully grouped to give a total estimated cost of pound sterling 7,373,539. An incremental, linear relationship was observed in the cost increases for each additional diagnosed complication. Mean annual inpatient age-standardised costs were pound sterling 434 for no complications, pound sterling 999 for one complication, pound sterling 1,641 for two, and pound sterling 2,462 for three. There were 5717 patients with diabetes who attended 25,334 outpatient appointments. The estimated cost for these outpatient appointments was pound sterling 1,833,232.
Minimising the number of complications in patients with diabetes would result in considerable cost offsets.
Diabetes Research and Clinical Practice 03/2005; 67(2):144-51. · 2.75 Impact Factor
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ABSTRACT: This study aims to provide the first estimates of the costs and effects of the large scale introduction of autologous transfusion technologies into the United Kingdom National Health Service.
A model was constructed to allow disparate data sources to be combined to produce estimates of the scale, costs, and effects of introducing four interventions. The interventions considered were preparing patients for surgery (PPS) clinics, preoperative autologous donation (PAD), intraoperative cell salvage (ICS), and postoperative cell salvage (PoCS).
The key determinants of cost per operation are the anticipated level of reductions in blood use, the mean level of blood use, mean length of stay, and the cost of the technology. The results show the potential for considerable reductions in blood use. The greatest reductions are anticipated to be through the use of PPS and ICS. Vascular surgery, transplant surgery, and cardiothoracic surgery appear to be the specialties that will benefit most from the technologies.
Several simplifications were used in the production of these estimates; consequently, caution should be used in their interpretation and use. Despite the drawbacks in the methods used in the study, the model shows the scale of the issue, the importance of gathering better data, and the form that data must take. Such preliminary modeling exercises are essential for rational policy development and to direct future research and discussion among stakeholders.
International Journal of Technology Assessment in Health Care 02/2005; 21(2):234-9. · 1.37 Impact Factor
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ABSTRACT: Obesity is a global health problem, and comprehensive economic evaluations of treatments for obesity are needed to assess how it can be best addressed. Understanding the relationship between quality of life and obesity is important if the effects of treatment are to be fully captured by economic evaluations. All published estimates of utility related to obesity are reviewed. It was evident that there was widespread variability in the methods and findings. The authors' analysis of data on 13,000 patients within the Health Outcomes Data Repository shows a clearer picture. Obesity has a direct impact on health-related quality of life, therefore, economic evaluations need to incorporate these effects.
Expert Review of Pharmacoeconomics & Outcomes Research 12/2004; 4(6):657-65.
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ABSTRACT: To quantify hospital costs prior to death for patients with and without diabetes.
Using the Cardiff Diabetes Database, mortality data from the UK Office of National Statistics for 1996 were linked to existing hospital records using probability matching techniques. Costs were attributed using a statistical costing technique (healthcare resource groups (HRGs)) with UK 2000 prices.
There were 4394 deaths of which 412 (9.4%) were for patients with diabetes. In the year before death 380 (92%) patients with diabetes (DM+) were admitted as an inpatient compared with 73% of those without diabetes (DM-), a relative rate of 1.27. Total inpatient costs were 12.2M UK pound sterling (20M US dollars) of which costs for patients with diabetes were 1.6M UK pound sterling (2.6M US dollars), accounting for 15.6% of revenue. This translates to a rate of 2.8M UK pound sterling (4.0M US dollars) per 100,000 population per year. The mean annual inpatient cost before death was UK pound 3997 (5676 US dollars) for DM+ compared with UK pound 2656 (3772 US dollars) for DM-. Mean annual outpatient costs ranged from 185 UK pound sterling (263 US dollars: year minus 4) to 248 UK pound sterling (352 US dollars: year minus 2) in DM+, and 91 UK pound sterling (129 US dollars: year minus 4) to 116 UK pound sterling (165 US dollars: year minus 2) in DM-. Mean annual outpatient costs associated with the care of people with diabetes are consistently higher: +80% at minus 1-year rising to +120% at minus 3 years.
The costs of inpatient care for all patients increases markedly in the final year of life. People with diabetes were found to be more financially costly, even in this stage of their care, than were people who did not have diabetes.
Diabetes Research and Clinical Practice 10/2004; 65(3):267-74. · 2.75 Impact Factor
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ABSTRACT: An aim of the National Primary Care Collaborative is to improve quality and access for patients in primary care using principles of Advanced Access.
To determine whether Advanced Access led to improved availability of appointments with general practitioners (GPs) and to examine GPs' views of the process.
Observational study.
Four hundred and sixty-two general practices in England participating in four waves of the collaborative during 2000 and 2001.
Regression analysis of the collaborative's monthly data on the availability of GP appointments for the 352 practices in waves 1-3, and a postal survey of lead GPs in all four waves. The main outcome measures were the change in mean time to the third available appointment with GPs, and the proportion of GPs thinking it worthwhile participating in the collaborative.
The time to the third available appointment improved from a mean of 3.6 to 1.9 days, difference = 1.7 days, 95% confidence interval (CI)= 1.4 to 2.0 days. It improved in two-thirds of practices (66% [219/331]), remained the same in 16% (53/331), and worsened in 18% (59/331). The majority of GPs in all four waves, 83% (308/371, 95% CI = 79 to 87), felt that it was worthwhile participating in the collaborative, although one in 12 practices would not recommend it. One-fifth of GPs cited a lack of resources as a constraint, and some expressed concerns about the trade-off between immediate access and continuity of care.
Advanced Access helped practices to improve availability of GP appointments, and was well received by the majority of practices.
British Journal of General Practice 06/2004; 54(502):334-40. · 1.83 Impact Factor
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ABSTRACT: We systematically reviewed published economic evaluations of systemic antifungal therapies and assessed their strengths and weaknesses. The study identified all economic evaluations published before May 2002 and critically appraised their methods using a published checklist. Over 1000 papers on antifungal treatments and costs were retrieved, 40 of which were economic evaluations. Fifteen of these were evaluations of systemic antifungal therapy. The majority of studies examined prophylaxis (11 out of 15), two examined empiric treatment and two examined the treatment of confirmed infections. Methods varied quite dramatically and the quality of the studies was, in general, very poor. Consequently, we were unable to find a coherent body of economic evidence for any particular patient group and/or indication. Three methodological issues were identified as requiring improvement in future economic evaluations of the prevention and treatment of systemic mucoses: cost estimates, outcome measures and evidence of effectiveness. Costs of both antifungal infection and treatment are important, and despite this, seven of the studies only collected cost information on drug acquisition costs. This is such a fundamental flaw that these studies should not be used to inform decision making on the use of antifungal medication. The estimation of costs in the other studies appeared appropriate, although limited reporting obscured other important issues, such as the appropriate use of per diem costs. Outcome measures were necessarily produced in all evaluations, yet only two studies produced cost-effectiveness ratios. This makes comparisons across studies very difficult. Also, small samples sizes meant that 'hard' outcome measures such as life-years saved could not be used, as deaths were rare within the studies. Both studies that produced incremental cost-effectiveness ratios were model-based studies. These allow simulations to be run on large cohorts of hypothetical patients, thus allowing differences in mortality between treatments to be evaluated. Evidence of effectiveness was limited, with many of the studies based on non-randomised clinical studies and consequently open to bias. Future clinical trials of the effectiveness of antifungal prophylaxis and treatment need to incorporate the collection of costs and economic outcome measures. Even quite simple analyses can be quite powerful, particularly when combined with modelling work to allow other data sources to be added.
PharmacoEconomics 02/2004; 22(7):421-33. · 2.66 Impact Factor
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ABSTRACT: To evaluate the clinical and cost impact of providing cognitive behaviour therapy (CBT) for insomnia (comprising sleep hygiene, stimulus control, relaxation and cognitive therapy components) to long-term hypnotic drug users in general practice.
A pragmatic randomised controlled trial with two treatment arms (a CBT treated 'sleep clinic' group, and a 'no additional treatment' control group), with post-treatment assessments commencing at 3 and 6 months.
Twenty-three general practices in Sheffield, UK.
Two hundred and nine serially referred patients aged 31-92 years with chronic sleep problems who had been using hypnotic drugs for at least 1 month (mean duration = 13.4 years).
At 3- and 6-month follow-ups patients treated with CBT reported significant reductions in sleep latency, significant improvements in sleep efficiency, and significant reductions in the frequency of hypnotic drug use (all P<0.01). Among CBT treated patients SF-36 scores showed significant improvements in vitality at 3 months (P<0.01). Older age presented no barrier to successful treatment outcomes. The total cost of service provision was 154.40 per patient, with a mean incremental cost per quality-adjusted life-year of 3416 (at 6 months). However, there was evidence of longer term cost offsets owing to reductions in sleeping tablet use and reduced utilisation of primary care services.
In routine general practice settings, psychological treatments for insomnia can improve sleep quality and reduce hypnotic consumption at a favourable cost among long-term hypnotic users with chronic sleep difficulties.
British Journal of General Practice 01/2004; 53(497):923-8. · 1.83 Impact Factor
