Private funding of elective hospital treatment in England and Wales, 1997-8: national survey

OUP accepted manuscript

Background

Varicose vein (VV) treatments have changed significantly in recent years leading to potential disparities in service provision. The aim of this study was to examine the trends in VV treatment in England and to identify disparities in the provision of day-case and inpatient treatments related to deprivation, ethnicity, and other demographic, and geographical factors.

Method

A population-based study using linked hospital episode statistics for England categorized VV procedures and compared population rates and procedure characteristics by ethnicity, deprivation quintile, and geographical area.

Results

A total of 311 936 people had 389 592 VV procedures between 2006/07 and 2017/18, with a further 63 276 procedures between 2018/19 and 2020/21. Procedure rates have reduced in all but the oldest age groups, whereas endovenous procedures have risen to more than 60 per cent of the total in recent years. In younger age groups there was a 20–30 per cent reduction in procedure rates for the least-deprived compared with the most-deprived quintiles. Non-white ethnicity was associated with lower procedure rates. Large regional and local differences were identified in standardized rates of VV procedures. In the most recent 5-year interval, the North-East region had a three-fold higher rate than the South-East region with evidence of greater variation between commissioners in overall rates, the proportion of endovenous procedures, and policies regarding bilateral treatments.

Conclusions

There are substantial geographical variations in the provision of treatment for VVs, which are not explained by demographic differences. These have persisted, despite the publication of guidelines from the National Institute for Health and Care Excellence, and many commissioners, and providers would seem to implement policies that are contrary to this guidance. Lower rates of procedures in less-deprived areas may reflect treatments carried out in private practice, which are not included in these data.

The economic impact of sight loss and blindness in the UK adult population

BACKGROUND

To quantify the economic impact of sight loss and blindness in the United Kingdom (UK) population, including direct and indirect costs, and its burden on health.

METHODS

Prevalence data on sight loss and blindness by condition, Census demographic data, data on indirect costs, and healthcare cost databases were used. Blindness was defined as best corrected visual acuity (BCVA) of < 6/60, and sight loss as BCVA < 6/12 to 6/60, in the better-seeing eye.

RESULTS

Sight loss and blindness from age-related macular degeneration (AMD), cataract, diabetic retinopathy, glaucoma and under-corrected refractive error are estimated to affect 1.93 (1.58 to 2.31) million people in the UK. Direct health care system costs were £3.0 billion, with inpatient and day care costs comprising £735 million (24.6%) and outpatient costs comprising £771 million (25.8%). Indirect costs amounted to £5.65 (5.12 to 6.22) billion. The value of the loss of healthy life associated with sight loss and blindness was estimated to be £19.5 (15.9 to 23.3) billion or £7.2 (5.9 to 8.6) billion, depending on the set of disability weights used. For comparison with other published results using 2004 disability weights and the 2008 estimates, the total economic cost of sight loss and blindness was estimated to be £28.1 (24.0 to 32.5) billion in 2013. Using 2010 disability weights, the estimated economic cost of sight loss and blindness was estimated to be £15.8 (13.5 to 18.3) billion in 2013.

CONCLUSIONS

The large prevalence of sight loss and blindness in the UK population imposes significant costs on public funds, private expenditure, and health. Prevalence estimates relied on dated epidemiological studies and may not capture recent advances in treatment, highlighting the need for population-based studies that track the prevalence of sight-impairing eye conditions and treatment effects over time.

Lower limb arthroplasty: can we produce a tool to predict outcome and failure, and is it cost-effective? An epidemiological study

Background

Although hip and knee arthroplasties are considered to be common elective cost-effective operations, up to one-quarter of patients are not satisfied with the operation. A number of risk factors for implant failure are known, but little is known about the predictors of patient-reported outcomes.

Objectives

(1) Describe current and future needs for lower limb arthroplasties in the UK; (2) describe important risk factors for poor surgery outcomes and combine them to produce predictive tools (for hip and knee separately) for poor outcomes; (3) produce a Markov model to enable a detailed health economic analysis of hip/knee arthroplasty, and for implementing the predictive tool; and (4) test the practicality of the prediction tools in a pragmatic prospective cohort of lower limb arthroplasty.

Design

The programme was arranged into four work packages. The first three work packages used the data from large existing data sets such as Clinical Practice Research Datalink, Hospital Episode Statistics and the National Joint Registry. Work package 4 established a pragmatic cohort of lower limb arthroplasty to test the practicality of the predictive tools developed within the programme.

Results

The estimated number of total knee replacements (TKRs) and total hip replacements (THRs) performed in the UK in 2015 was 85,019 and 72,418, respectively. Between 1991 and 2006, the estimated age-standardised rates (per 100,000 person-years) for a THR increased from 60.3 to 144.6 for women and from 35.8 to 88.6 for men. The rates for TKR increased from 42.5 to 138.7 for women and from 28.7 to 99.4 for men. The strongest predictors for poor outcomes were preoperative pain/function scores, deprivation, age, mental health score and radiographic variable pattern of joint space narrowing. We found a weak association between body mass index (BMI) and outcomes; however, increased BMI did increase the risk of revision surgery (a 5-kg/m2rise in BMI increased THR revision risk by 10.4% and TKR revision risk by 7.7%). We also confirmed that osteoarthritis (OA) severity and migration pattern of the hip predicted patient-reported outcome measures. The hip predictive tool that we developed performed well, with a correctedR2of 23.1% and had good calibration, with only slight overestimation of Oxford Hip Score in the lowest decile of outcome. The knee tool developed performed less well, with a correctedR2of 20.2%; however, it had good calibration. The analysis was restricted by the relatively limited number of variables available in the extant data sets, something that could be addressed in future studies. We found that the use of bisphosphonates reduced the risk of revision knee and hip surgery by 46%. Hormone replacement therapy reduced the risk by 38%, if used for at least 6 months postoperatively. We found that an increased risk of postoperative fracture was prevented by bisphosphonate use. This result, being observational in nature, will require confirmation in a randomised controlled trial. The Markov model distinguished between outcome categories following primary and revision procedures. The resulting outcome prediction tool for THR and TKR reduced the number and proportion of unsatisfactory outcomes after the operation, saving NHS resources in the process. The highest savings per quality-adjusted life-year (QALY) forgone were reported from the oldest patient subgroups (men and women aged ≥ 80 years), with a reported incremental cost-effectiveness ratio of around £1200 saved per QALY forgone for THRs. In the prospective cohort of arthroplasty, the performance of the knee model was modest (R2 = 0.14) and that of the hip model poor (R2 = 0.04). However, the addition of the radiographic OA variable improved the performance of the hip model (R2 = 0.125 vs. 0.110) and high-sensitivity C-reactive protein improved the performance of the knee model (R2 = 0.230 vs. 0.216). These data will ideally need replication in an external cohort of a similar design. The data are not necessarily applicable to other health systems or countries.

Conclusion

The number of total hip and knee replacements will increase in the next decade. High BMI, although clinically insignificant, is associated with an increased risk of revision surgery and postoperative complications. Preoperative pain/function, the pattern of joint space narrowing, deprivation index and level of education were found to be the strongest predictors for THR. Bisphosphonates and hormone therapy proved to be beneficial for patients undergoing lower limb replacement. The addition of new predictors collected from the prospective cohort of arthroplasty slightly improved the performance of the predictive tools, suggesting that the potential improvements in both tools can be achieved using the plethora of extra variables from the validation cohort. Although currently it would not be cost-effective to implement the predictive tools in a health-care setting, we feel that the addition of extensive risk factors will improve the performances of the predictive tools as well as the Markov model, and will prove to be beneficial in terms of cost-effectiveness. Future analyses are under way and awaiting more promising provisional results.

Future work

Further research should focus on defining and predicting the most important outcome to the patient.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Risk Factors for Cataracts Treated Surgically in Postmenopausal Women

PURPOSE

To identify risk factors for cataracts treated surgically in postmenopausal women.

DESIGN

Population-based, prospective cohort study.

PARTICIPANTS

A total of 1 312 051 postmenopausal women in the UK Million Women Study, aged 56 years on average (standard deviation [SD], 4.8), without previous cataract surgery, hospital admission with cataracts, or cancer at baseline, were followed for cataracts treated surgically.

METHODS

Cox regression was used to calculate adjusted relative risks (RRs) for cataract surgery by lifestyle factors, treatment for diabetes, reproductive history, and use of hormonal therapies.

MAIN OUTCOME MEASURES

Cataract surgery identified by linkage to central National Health Service (NHS) records for inpatient and day-patient admissions (Hospital Episode Statistics for England and Scottish Morbidity Records in Scotland).

RESULTS

Overall, 89 343 women underwent cataract surgery during an average of 11 (SD, 3) years of follow-up. Women with diabetes were at greatest risk (diabetes vs. no diabetes RR, 2.90; 95% confidence interval [CI], 2.82-2.97). Other factors associated with an increased risk of cataract surgery were current smoking (current smokers of ≥15 cigarettes/day vs. never smokers RR, 1.26; 95% CI, 1.23-1.30) and obesity (body mass index [BMI] ≥30 vs. <25 kg/m(2); RR, 1.12; 95% CI, 1.10-1.14).

CONCLUSIONS

Diabetes, smoking, and obesity were risk factors for cataract surgery. Alcohol use, physical activity, reproductive history, and use of hormonal therapies had little, if any, association with cataract surgery risk.

The effect of waiting time and distance on hospital choice for English cataract patients

This paper applies latent-class multinomial logit models to the choice of hospital for cataract operations in the UK NHS. We concentrate on the effects of travel time and waiting time and especially on estimating the waiting time elasticity of demand. Models including hospital fixed effects rely on changes over time in waiting time to indentify coefficients. We show how using a latent-class multinomial logit model characterises the unobserved heterogeneity in GP practices' choice behaviour and affects the estimated elasticities of travel time and waiting time. The models estimate waiting time elasticities of demand of approximately -0.1, comparable with previous waiting time-demand models. For the average waiting time elasticity, the simple multinomial logit models are good approximations of the latent-class logit results.

Health care for older persons in England and the United States: a contrast of systems and values

This article extends previous comparisons of access to health care for older persons in England and the United States by comparing rates of avoidable hospital conditions as a proxy for primary care access and by examining the distribution of care within these older populations. Drawing on hospital data from the two countries, we find that older persons in the United States, particularly those over the age of seventy-five, receive far more revascularizations than do older persons in England. Differences in the use of lower-joint replacement are not as great, but we are unable to assess differences in the need for these procedures. Although older persons have greater access to specialty care in the United States, there appears to be much better access to primary care in England. We are unable to draw comparisons on the extent of inequalities in access to health care, although in the United States there is evidence of inequalities in access by race, and in England we confirm earlier studies that find inequalities by level of deprivation. These findings are discussed in the context of the political debates over access to care and rationing in the two countries.

Equity in access to total joint replacement of the hip and knee in England: cross sectional study

OBJECTIVE

To explore geographical and sociodemographic factors associated with variation in equity in access to total hip and knee replacement surgery.

DESIGN

Combining small area estimates of need and provision to explore equity in access to care.

SETTING

English census wards.

SUBJECTS

Patients throughout England who needed total hip or knee replacement and numbers who received surgery.

MAIN OUTCOME MEASURES

Predicted rates of need (derived from the Somerset and Avon Survey of Health and English Longitudinal Study of Ageing) and provision (derived from the hospital episode statistics database). Equity rate ratios comparing rates of provision relative to need by sociodemographic, hospital, and distance variables.

RESULTS

For both operations there was an "n" shaped curve by age. Compared with people aged 50-59, those aged 60-84 got more provision relative to need, while those aged >or=85 received less total hip replacement (adjusted rate ratio 0.68, 95% confidence interval 0.65 to 0.72) and less total knee replacement (0.87, 0.82 to 0.93). Compared with women, men received more provision relative to need for total hip replacement (1.08, 1.05 to 1.10) and total knee replacement (1.31, 1.28 to 1.34). Compared with the least deprived, residents in the most deprived areas got less provision relative to need for total hip replacement (0.31, 0.30 to 0.33) and total knee replacement (0.33, 0.31 to 0.34). For total knee replacement, those in urban areas got higher provision relative to need, but for total hip replacement it was highest in villages/isolated areas. For total knee replacement, patients living in non-white areas received more provision relative to need (1.04, 1.00 to 1.07) than those in predominantly white areas, but for total hip replacement there was no effect. Adjustment for hospital characteristics did not attenuate the effects.

CONCLUSIONS

There is evidence of inequity in access to total hip and total knee replacement surgery by age, sex, deprivation, rurality, and ethnicity. Adjustment for hospital and distance did not attenuate these effects. Policy makers should examine factors at the level of patients or primary care to understand the determinants of inequitable provision.

Secondary care treatment of patients with varicose veins in National Health Service England: at least how it appeared on a National Health Service website

Objectives

This study aimed to assess the trends and regional variations in secondary care treatment of patients with varicose veins in National Health Service (NHS) England based on data published by the Hospital Episode Statistics which was freely and readily available to the public and health-care policy-makers.

Methods

Hospital Episode Statistics data for patients being treated for varicose veins, and UK Statistics Authority population estimates in all 28 Strategic Health Authorities (SHAs) in England from 2002 to 2006 were retrieved and analysed.

Results

Between 2002 and 2006 there was a 20% overall reduction (46,190–37,135) in the total number of varicose vein procedures performed in NHS England per year. The number of varicose vein procedures performed per 100,000 population per year varied significantly across the SHAs ( P < 0.0001). Similarly, significant regional variations were also noted in the frequency of primary procedures of greater and small saphenous vein ( P < 0.0001). During this time, injection sclerotherapy was only performed in 15 (53.6%) SHAs. The annual proportion of varicose vein procedures performed as daycases had increased from 56% to 64% during the period.

Conclusion

From 2002 to 2006 there was an overall reduction in the total number of varicose vein procedures performed in NHS England with major regional variations.

Separate and joint effects of alcohol and smoking on the risks of cirrhosis and gallbladder disease in middle-aged women

The separate and joint effects of alcohol and smoking on incidences of liver cirrhosis and gallbladder disease were examined in a prospective study of 1,290,413 United Kingdom women (mean age, 56 years) recruited during 1996-2001. After a mean follow-up of 6.1 years (1996-2005), incidence rates of cirrhosis and gallbladder disease were 1.3 per 1,000 persons (n = 2,105) and 15 per 1,000 persons (n = 23,989), respectively, over 5 years. Cirrhosis risk increased with increasing alcohol consumption, while the risk of gallbladder disease decreased (P(trend) < 0.0001 for each). Comparing women who drank > or =15 units/week with those who drank 1-2 units/week, the relative risk was 4.32 (95% confidence interval (CI): 3.71, 5.03)) for cirrhosis and 0.59 (95% CI: 0.55, 0.64) for gallbladder disease. Increasing numbers of cigarettes smoked daily increased the risk of both conditions (P(trend) < 0.0001 for each). Comparing current smokers of > or =20 cigarettes/day with never smokers, the relative risk was 3.76 (95% CI: 3.25, 4.34) for cirrhosis and 1.29 (95% CI: 1.22, 1.37) for gallbladder disease. Effects of alcohol and smoking were more than multiplicative for cirrhosis (P(interaction) = 0.02) but not for gallbladder disease (P(interaction) = 0.4). Findings indicate that alcohol and smoking affect the risks of the 2 conditions in different ways. For cirrhosis, alcohol and smoking separately increase risk, and their joint effects are particularly hazardous. For gallbladder disease, alcohol reduces risk and smoking results in a small risk increase.

Need for and receipt of hip and knee replacement--a national population survey

OBJECTIVES

Hip and knee joint replacements are effective, and yet little is known about how closely the need for joint replacement matches supply in different population groups. Our objective was to compare the prevalence of existing joint replacements with that of need in population groups in England.

METHODS

A total of 7101 people aged 60 yrs or older, representative of the population of England, were interviewed. Participants were asked about both receipt and need for joint replacement, socio-economic status and co-morbidity. 'Need' classification was based on hip or knee pain and difficulty walking, with adjustment for potential surgical contraindications. Associations between participants' characteristics and both need and receipt were estimated.

RESULTS

The prevalence of existing joint replacement (receipt) was 6% [95% confidence intervals (CI) 5, 6], and this was lower in the North than the South [adjusted odds ratio (OR) 0.72, CI 0.53, 0.96]. In contrast, the prevalence of estimated need was higher in the North (OR 1.27, CI 1.03, 1.58). Need was greater in women than men (OR 1.30, CI 1.09, 1.53), and showed an increasing gradient from the wealthiest to poorest quintile (ORs 1.00, 1.52, 2.18, 2.49, 3.23). In contrast, receipt did not differ significantly by sex or socio-economic group.

CONCLUSIONS

People living in the North of England, women and the less wealthy experience relatively high levels of need, yet do not receive relatively more hip and knee joint replacements.

The effects of surgical volumes and training centre status on outcomes following total joint replacement: analysis of the Hospital Episode Statistics for England

OBJECTIVE

Previous work from other countries has shown a significant inverse relationship between the number of some surgical procedures undertaken in a hospital and in an adverse outcomes. In the light of the changing nature of the provision of joint replacements in the United Kingdom, we have examined the effects of surgical volumes and the presence/absence of training centre status, on outcomes following total joint replacement (TJR) in England.

METHODS

Analysis of the Hospital Episode Statistics (HES) on all hip/knee joint replacements in English National Health Service (NHS) trusts between financial years 1997 and 2002. Exposures explored were the volume of hip/knee replacements per annum in an NHS trust, training centre status and whether the admission was routine or emergency. Four surrogate measures of adverse outcome were assessed: 30-day in-hospital mortality, length of stay in hospital, readmission within a year and surgical revision within 5 years. Age and sex were controlled for as potential confounders.

RESULTS

Data from a total of 281 360 hip replacements and 211 099 knee replacements were examined. HES data show that the numbers of TJRs performed in low volume trusts are small and decreasing. Adverse outcomes were also uncommon. Nevertheless, significant associations between adverse outcomes and low volume units, and better outcomes in training centres, were detected. For example, the odds ratio (OR) for in-hospital death within 30 days of hip replacement in trusts doing <50 hip/replacements per annum is 1.98 [95% confidence interval (95% CI) = 1.13-3.47] compared with trusts doing 251-500 operations/annum. Similarly, surgery in non-training centres is more likely to result in mortality than that in training centres (OR = 1.25, 95% CI = 1.05-1.48). The examination of surgical revision indicated adverse outcomes in higher volume units; this may be due to case-mix.

CONCLUSION

In England, there are fewer adverse events following TJR in high volume centres and in orthopaedic training centres. Standardization of procedures may account for this finding. The data have implications for private practice in the United Kingdom and for the current move to undertake TJRs in Independent Sector Treatment Centres.

Decreasing strabismus surgery

AIM

To determine whether there has been a consistent change across countries and healthcare systems in the frequency of strabismus surgery in children over the past decade.

METHODS

Retrospective analysis of data on all strabismus surgery performed in NHS hospitals in England and Wales, on children aged 0-16 years between 1989 and 2000, and between 1994 and 2000 in Ontario (Canada) hospitals. These were compared with published data for Scotland, 1989-2000.

RESULTS

Between 1989 and 1999-2000 the number of strabismus procedures performed on children, 0-16 years, in England decreased by 41.2% from 15 083 to 8869. Combined medial rectus recession with lateral rectus resection decreased from 5538 to 3013 (45.6%) in the same period. Bimedial recessions increased from 489 to 762, oblique tenotomies from 43 to 121, and the use of adjustable sutures from 29 to 44, in 2000. In Ontario, operations for squint decreased from 2280 to 1685 (26.1%) among 0-16 year olds between 1994 and 2000.

CONCLUSION

The clinical impression of decrease in the frequency of paediatric strabismus surgery is confirmed. In the authors' opinion this cannot be fully explained by a decrease in births or by the method of healthcare funding. Two factors that might have contributed are better conservative strabismus management and increased subspecialisation that has improved the quality of surgery and the need for re-operation. This finding has a significant impact upon surgical services and also on the training of ophthalmologists.

Gender and age inequity in the provision of coronary revascularisation in England in the 1990s: is it getting better?

Although the mortality and incidence of coronary heart disease (CHD) in England and Wales has declined in recent years, an ageing population has contributed to keeping the prevalence of CHD largely unchanged. Evidence suggests that revascularisation procedures have contributed not only to this decline in mortality, but also to the decline in morbidity from heart disease, and to improvements in quality of life, even in old age. Despite clinical evidence of benefit, revascularisation is less often provided for older people and for women. This paper considers the equity of the provision of revascularisation according to need by gender and age using the Hospital Episodes Statistics (HES) database which includes all NHS hospital admissions in England. Trends from 1991 to 1999 were examined comparing admissions for acute myocardial infarction (as a proxy indicator of need in the absence of direct measures) and the procedures coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA). The rates of CABG and PTCA have increased dramatically by 72% and 48%, respectively, between 1991/3 and 1997/9. Making allowance for differences in need, to achieve equitable provision with men, over 12,000 extra CABG and over 5000 PTCA procedures would be required for women, amounting to 19% and 10% increases in the total volume of each procedure, respectively. Similarly, attempting to meet need up to the age of 79 years would require over 13,000 extra CABG and over 13,000 PTCA procedures for men, and an additional 14,300 CABG and almost 10,000 extra PTCA procedures for women, representing 42% and 40% increases in CABG and PTCA, respectively. As women tend to present with CHD at older ages this indicates that they may be the victims of a 'double whammy' of inequity. Moreover, these inequities have remained constant through the study period. Possible explanations for this shortfall of provision are proposed.

Motivation and values of hospital consultants in south-east England who work in the national health service and do private practice

In the UK, a small private health care sector has always existed alongside the national health service (NHS). The conventional assumption is that doctors who work as salaried employees of the NHS are guided in their clinical practice by professional values which encourage them to put their patients' interests first. A common suspicion is that doctors undertaking fee-for-service practice in the private sector are motivated by self-interest, with commitment to their patients compromised by consideration for their purse. The great majority of hospital consultants are salaried employees of the NHS, but most also undertake some private practice. This paper uses findings from an interview study of 60 surgeons and physicians engaged in dual practice of this kind to investigate their reasons for working in this way and look at how they reconcile their personal, professional and public sector values and responsibilities with the temptations of the market. The existence of the private sector and their own engagement in it was regarded by almost all respondents as a net benefit, not only to themselves and their private patients, but also to the NHS, so long as they handled it properly. The interviews revealed a complex range of beliefs and assumptions through which these doctors justify their activities and a variety of informal principles for dealing with such conflicts of interest as they acknowledge. Neither their values nor their actions can be adequately explained using generic concepts of professional self-interest or public service values without consideration of what such concepts represented in the specific social, economic, professional and policy context of health care in south-east England at the time of the study.

Trends in hip and knee joint replacement: socioeconomic inequalities and projections of need

OBJECTIVES

To examine trends in primary and revision joint (hip and knee) replacement in England between 1991 and 2000.

METHODS

Analysis of hospital episodes statistics between 1 April 1991 and 30 March 2001 for total hip replacement (THR) and total knee replacement (TKR). Descriptive statistics and regression modelling were used to summarise patients' demographic and clinical characteristics and to explore variations in joint surgery rates by age, sex, and deprivation.

RESULTS

Between 1991 and 2000, the incidence of primary THR increased by 18%, while the incidence of revision THR more than doubled. The incidence of primary TKR doubled, with revision TKR increasing by 300%. Over the 10 year period, the proportion of THR episodes that involved revision operations rose from 8% to 20%. Substantial variations in operation rates by socioeconomic status were seen, with the most deprived fifth of the population experiencing significantly lower rates. Projections estimate that primary THR numbers could rise by up to 22% by the year 2010, with primary TKR numbers rising by up to 63%.

CONCLUSIONS

Provision of joint replacement surgery in English NHS hospitals has increased substantially over the past decade. Revision operations in particular have increased markedly. The growth in primary operations has mostly occurred among those aged 60 years and over; rates among young people have changed very little. There is a significant deprivation based gradient in rates. If current trends continue there would be almost 47 000 primary hip and 54 000 primary knee operations annually by 2010.

Gender and the treatment of heart disease in older persons in the United States, France, and England: a comparative, population-based view of a clinical phenomenon

BACKGROUND

Gender disparities in the treatment of coronary artery disease (CAD) have been extensively documented in studies from the United States. However, they have been less well studied in other countries and, to our knowledge, have not been investigated at the more disaggregated spatial level of cities.

OBJECTIVE

This study tests the hypothesis that there is a common international pattern of gender disparity in the treatment of CAD in persons aged > or =65 years by analyzing data from the United States, France, and England and from their largest cities-New York City and its outer boroughs, Paris and its First Ring, and Greater London.

METHODS

This was an ecological study based on a retrospective analysis of comparable administrative data from government health databases for the 9 spatial units of analysis: the 3 countries, their 3 largest cities, and the urban cores of these 3 cities. A simple index was used to assess the relationship between treatment rates and a measure of CAD prevalence by gender among age-adjusted cohorts of patients. Differences in rates were examined by univariate analysis using the Student t test for statistical differences in mean values.

RESULTS

Despite differences in health system characteristics, including health insurance coverage, availability of medical resources, and medical culture, we found consistent gender differences in rates of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting across the 9 spatial units. The rate of interventional treatment in women with CAD was less than half that in men. This difference persisted after adjustment for the prevalence of heart disease.

CONCLUSIONS

A consistent pattern of gender disparity in the interventional treatment of CAD was seen across 3 national health systems with known differences in patterns of medical practice. This finding is consistent with the results of clinical studies suggesting that gender disparities in the treatment of CAD are due at least in part to the underdiagnosis of CAD in women.

Reduction in the use of surgery for glue ear: did national guidelines have an impact?

BACKGROUND

It is widely accepted that the passive dissemination of national clinical guidance has little or no impact on practice.

OBJECTIVE

To assess the impact in England of an Effective Health Care bulletin on childhood surgery for glue ear issued in 1992 and to understand the reasons for any change (or lack of change) in practice that ensued.

METHOD

Time series analysis of the rate of use of surgery by children under 10 years of age from 1975 to 1997/8 in 13 English health districts.

RESULTS

Following a rise in the rate of surgery in public (National Health Service) hospitals from 1975 to 1985, the rate declined by 1.6% a year from 1986 to 1992/3. Following publication of the guidelines in November 1992, the rate of decline increased to 10.1% a year. Even after allowing for a slight increase in the use of independent (private) hospitals between 1992/3 and 1997/8, the overall rate of decline was at least 7.9%. It appears that the rate of referral of cases by primary care physicians (general practitioners) halved during this period. Several contextual factors are thought to have contributed to the effect of the guidelines, including pre-existing professional concern about the value of surgery, the introduction of an internal market into the NHS, and growing apprehension among parents fuelled by scepticism in the mass media. During this unprecedented period of rapid change in usage, staff delivering the service remained unaware of the alterations in their own practice.

CONCLUSIONS

Passive dissemination of national guidelines can accelerate an existing trend in clinical practice if the context is hospitable. Policy makers should identify and target such situations.

The demand for elective surgery in a public system: time and money prices in the UK National Health Service

We construct a model of the admission process for patients from general practices for elective surgery in the UK National Health Service. Public patients face a positive waiting time, but a zero money price. Fundholding practices faced a positive money price for each patient admitted. The model is tested with data on general practice admission rates for cataract procedures in an English Health Authority. Admission rates are negatively related to waiting times and distance to hospital. Practices respond to financial incentives as predicted by the model: fundholding practices have lower admission rates than non-fundholders and respond differently to changes in waiting times and patient characteristics.

Private medical services in acute-care hospitals in Israel

The objective of this study was to assess the proposed introduction of out-of-pocket funded inpatient and outpatient services (abbreviated as PMS) into government acute-care hospitals in Israel. This issue of public-private mix in not-for-profit hospitals is discussed in terms of the experience with PMS gained in selected advanced market economies. Then, the major contours of the Israeli system of health care, and the gradual evolving of patient-financed medical services within government acute-care hospitals in Israel, is described. The experience gained in the few public hospitals in Jerusalem that have been operating PMS is assessed critically. The concluding part reviews the advantages and disadvantages of these developments in public and government acute-care hospitals in Israel. It is concluded that PMS in public hospitals in Israel represents a policy aimed primarily at benefiting a select group of senior physicians in those hospitals.

Hysterectomy prevalence and adjusted cervical and uterine cancer rates in England and Wales

OBJECTIVE

To present recent trends in cervical and uterine cancer adjusted for true population at risk, using accurate estimates of the prevalence of hysterectomy where the cervix has been removed or not. To describe trends and projections of hysterectomy incidence and prevalence with and without cervix removal.

DESIGN

Collation of available NHS and private sector information.

SETTING

England and Wales.

SAMPLE

NHS operations from Hospital Inpatient Enquiry, Hospital Episode Statistics and Hospital Activity Analysis for England and Wales. Private sector data from surveys with up to 97% coverage. METHODS AND MAIN OUTCOME: Measures NHS data by 5-year age group, year and operation type were collated for 1961-1995. non-NHS operations for 1981, 1986, and 1992/3 were back-projected. Hysterectomy incidence rates, 1961-95, were back-projected to estimate prevalence rates by accumulation. True populations at risk of disease and hysterectomy were calculated by applying one minus the relevant hysterectomy prevalence rates to the population by age group and year.

RESULTS

When based on the true population at risk, the age standardised cervical cancer incidence rate in 1992 was 14.4 per 100,000, compared with 12.6 when based on the all women population estimate. Incidence rates for earlier years were also affected, but there was no important effect on the rate of change over time. Absolute changes for uterine cancer are greater because the true population at risk is proportionally smaller particularly at the older ages, but there are again no major effects on the rate of change. By 1995 2.3 million women in England and Wales were without a uterus, with a peak prevalence of 21.3% in the age group 55-59. Projections based on 1995 incidence rates show hysterectomy prevalence for the screened age groups, 25-64, will now fall. Subtotal hysterectomy is 3.5% of operations and increasing.

CONCLUSIONS

True populations at risk must be used to assess the impact of screening if further reductions in cervix cancer incidence rates are not to be masked. It is essential to monitor hysterectomy by type, as subtotal hysterectomy is becoming more common. Hysterectomy incidence may have peaked. Hysterectomy prevalence in England and Wales may not be as high as would be estimated from some regional studies.