Modelling the lifetime cost-effectiveness of radical prostatectomy, radiotherapy and active monitoring for men with clinically localised prostate cancer from median 10-year outcomes in the ProtecT randomised trial

BACKGROUND

Optimal management strategies for clinically localised prostate cancer are debated. Using median 10-year data from the largest randomised controlled trial to date (ProtecT), the lifetime cost-effectiveness of three major treatments (radical radiotherapy, radical prostatectomy and active monitoring) was explored according to age and risk subgroups.

METHODS

A decision-analytic (Markov) model was developed and informed by clinical input. The economic evaluation adopted a UK NHS perspective and the outcome was cost per Quality-Adjusted Life Year (QALY) gained (reported in UK£), estimated using EQ-5D-3L.

RESULTS

Costs and QALYs extrapolated over the lifetime were mostly similar between the three randomised strategies and their subgroups, but with some important differences. Across all analyses, active monitoring was associated with higher costs, probably associated with higher rates of metastatic disease and changes to radical treatments. When comparing the value of the strategies (QALY gains and costs) in monetary terms, for both low-risk prostate cancer subgroups, radiotherapy generated the greatest net monetary benefit (£293,446 [95% CI £282,811 to £299,451] by D'Amico and £292,736 [95% CI £284,074 to £297,719] by Grade group 1). However, the sensitivity analysis highlighted uncertainty in the finding when stratified by Grade group, as radiotherapy had 53% probability of cost-effectiveness and prostatectomy had 43%. In intermediate/high risk groups, using D'Amico and Grade group > = 2, prostatectomy generated the greatest net monetary benefit (£275,977 [95% CI £258,630 to £285,474] by D'Amico and £271,933 [95% CI £237,864 to £287,784] by Grade group). This finding was supported by the sensitivity analysis. Prostatectomy had the greatest net benefit (£290,487 [95% CI £280,781 to £296,281]) for men younger than 65 and radical radiotherapy (£201,311 [95% CI £195,161 to £205,049]) for men older than 65, but sensitivity analysis showed considerable uncertainty in both findings.

CONCLUSION

Over the lifetime, extrapolating from the ProtecT trial, radical radiotherapy and prostatectomy appeared to be cost-effective for low risk prostate cancer, and radical prostatectomy for intermediate/high risk prostate cancer, but there was uncertainty in some estimates. Longer ProtecT trial follow-up is required to reduce uncertainty in the model.

TRIAL REGISTRATION

Current Controlled Trials number, ISRCTN20141297: http://isrctn.org (14/10/2002); ClinicalTrials.gov number, NCT02044172: http://www.clinicaltrials.gov (23/01/2014).

31 A multi-site retrospective case note review for clinical practices of constipation in specialist palliative care settings

Background

Constipation is a common symptom for patients receiving palliative care. Whilst national clinical guidelines are available on the management of constipation for people with advanced cancer in specialist palliative care (SPC) settings questions exist around clinical practice and the extent to which the guidelines are implemented in practice. This study examine current clinical practice for management of constipation for patients with advanced cancer in SPC settings.

Methods

A multi-site retrospective case-note review was conducted consisting of 150 patient case-notes from three SPC units across the United Kingdom between August 2016 and May 2017. Descriptive statistics were used to compare clinical practices to national policy guidelines for constipation.

Results

A physical exam and bowel history was recorded for 109 patients (73%). Whilst the Bristol Stool Chart was used frequently across sites (96%) involvement of the multidisciplinary team varied. Almost a third of patient charts (27%) recorded no evidence of non-pharmacological management strategies. Pharmacological management was recorded frequently with sodium docusate or senna as the preferred laxatives across all sites however 33% of patient charts recorded no information on the titration of laxatives. There were no consistent management strategies recorded for opioid induced constipation or bowel obstruction

Conclusion

Assessment and management of constipation in SPC settings is highly variable. Variations in assessment; limited use of non-pharmacological and preventative strategies and absence of consistent strategies for opioid induced constipation or bowel obstruction are evident. Further education is needed to equip HCPs with the necessary knowledge and skills to assess and manage constipation.

References

. Friedrichsen M, Erichsen E. The lived experience of constipation in cancer patients in palliative hospital-based home care. Int J Palliat Nurs [Internet] 2004;10(7):321–5. Available from: http://search.ebscohost.com/login.aspx?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl?=13576321&A?N=13991056&h=XKMF4r08srZuhDY0j7C95oLLyYKNHUcvoeEuhyXNnsIM2BI%2BEhmcY1pPP%2BN1pvrMzQ9Bn9b5j45X6WzyBRydEA%3D%3D&crl=c [Accessed: 21 August 2017]

. Gilbert EH, et al. Chart reviews in emergency medicine research: Where are the methods?Annals of Emergency Medicine1996;27(3):305–8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/8599488 [Accessed: 17 May 2018]

. National Clinical Effectiveness Committee. Management of constipation in adult patients receiving palliative care national clinical guideline No. 10November 2015.

. Tvistholm N, Munch L, Danielsen AK. Constipation is casting a shadow over everyday life? A systematic review on older people’s experience of living with constipation [Internet]. Journal of Clinical Nursing2017;26:902–14. Available from: http://doi.wiley.com/10.1111/jocn.13422 [Accessed: 21 August 2017]

. Wickson-griffiths A, et al.Revisiting retrospective chart review: An evaluation of nursing home palliative and end-of-life care research. Palliative Medicine Care2014;1(2):8. Available at: www.symbiosisonlinepublishing.com [Accessed: 23 November 2017]

32 Examining the key factors impacting on the implementation of an educational program on constipation in specialist palliative care

Introduction

Constipation is one of the most common symptoms in patients in specialist palliative care (SPC) settings and can cause considerable physical psychological and social suffering for the patient and their family. Due to the high variability in constipation assessment and management in SPC settings questions exist around how to implement an educational program in practice to address this clinical gap.

Aim

To develop and test the feasibility and acceptability of a novel educational intervention for HCPs to manage constipation experienced by people in SPC settings.

Method

Using the MRC framework for complex interventions and guided by the consolidated framework for implementation research an online resource was developed considering the content context and processes for implementation.

Results

Assessment prevention and management were identified as the core aspects. Six sessions with theoretical content application to practice and reflection through interacting with colleagues were developed in line with the best available evidence. Incentives including an educational bursary and alignment with revalidation and support from senior management champions and the research team were identified as key elements needed successful implementation. Funding IT infrastructure and attitudes to the content have been flagged as potential barriers to success.

Conclusion

A six week blended program covering the key concepts for assessment and management of constipation in palliative care has been created. Content evidence from the literature and empirical data on the preferred structure and method of delivery as well as key considerations of the contextual factors have been identified as key factors for implementation.

References

. Craig P, et al.Developing and evaluating complex interventions: The new medical research council guidance. BMJ Clinical Research Ed2008;337(October):a1655. Available at: http://discovery.ucl.ac.uk/168426/

. Damschroder LJ, et al. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science2009;4(50).

. Friedrichsen M, Erichsen E. The lived experience of constipation in cancer patients in palliative hospital-based home care. Int J Palliat Nurs [Internet] 2004;10(7):321–5. Available from: http://search.ebscohost.com/login.aspx?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl?=13576321&AN=13991056&h=XKMF4r08srZuhDY0j7C95oLLyYKNHUcvoeEuhyXNnsIM2BI%2BEhmcY1pPP%2BN1pvrMzQ9Bn9b5j45X6WzyBRydEA%3D%3D&crl=c [Accessed: 2017 August 21]

. Tvistholm N, Munch L, Danielsen AK. Constipation is casting a shadow over everyday life? A systematic review on older people’s experience of living with constipation [Internet]. Journal of Clinical Nursing2017;26:902–14. Available from: http://doi.wiley.com/10.1111/jocn.13422 [Accessed: 2017 August 21]

A longitudinal assessment of the responsiveness of the ICECAP-A in a randomised controlled trial of a knee pain intervention

PURPOSE

The ICECAP-A is a simple measure of capability well-being for use with the adult population. The descriptive system is made up of five key attributes: Stability, Attachment, Autonomy, Achievement and Enjoyment. Studies have begun to assess the psychometric properties of the measure, including the construct and content validity and feasibility for use. This is the first study to use longitudinal data to assess the responsiveness of the measure.

METHODS

This responsiveness study was completed alongside a randomised controlled trial comparing three physiotherapy-led exercise interventions for older adults with knee pain attributable to osteoarthritis. Anchor-based methodologies were used to explore the relationship between change over time in ICECAP-A score (the target measure) and change over time in another measure (the anchor). Analyses were completed using the non-value-weighted and value-weighted ICECAP-A scores. The EQ-5D-3L was used as a comparator measure to contextualise change in the ICECAP-A. Effect sizes, standardised response means and t tests were used to quantify responsiveness.

RESULTS

Small changes in the ICECAP-A scores were seen in response to underlying changes in patients' health-related quality of life, anxiety and depression. Non-weighted scores were slightly more responsive than value-weighted scores. ICECAP-A change was of comparable size to change in the EQ-5D-3L reference measure.

CONCLUSION

This first analysis of the responsiveness using longitudinal data provides some positive evidence for the responsiveness of the ICECAP-A measure. There is a need for further research in those with low health and capability, and experiencing larger underlying changes in quality of life.

A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of 'PhysioDirect' telephone assessment and advice services for physiotherapy

BACKGROUND

As a result of long delays for physiotherapy for musculoskeletal problems, several areas in the UK have introduced PhysioDirect services in which patients telephone a physiotherapist for initial assessment and treatment advice. However, there is no robust evidence about the effectiveness, cost-effectiveness or acceptability to patients of PhysioDirect.

OBJECTIVE

To investigate whether or not PhysioDirect is equally as clinically effective as and more cost-effective than usual care for patients with musculoskeletal (MSK) problems in primary care.

DESIGN

Pragmatic randomised controlled trial to assess equivalence, incorporating economic evaluation and nested qualitative research. Patients were randomised in 2 : 1 ratio to PhysioDirect or usual care using a remote automated allocation system at the level of the individual, stratifying by physiotherapy site and minimising by sex, age group and site of MSK problem. For the economic analysis, cost consequences included NHS and patient costs, and the cost of lost production. Cost-effectiveness analysis was carried out from the perspective of the NHS. Interviews were conducted with patients, physiotherapists and their managers.

SETTING

Four community physiotherapy services in England.

PARTICIPANTS

Adults referred by general practitioners or self-referred for physiotherapy for a MSK problem.

INTERVENTIONS

Patients allocated to PhysioDirect were invited to telephone a senior physiotherapist for initial assessment and advice using a computerised template, followed by face-to-face care when necessary. Patients allocated to usual care were put on to a waiting list for face-to-face care.

MAIN OUTCOME MEASURES

Primary outcome was the Short Form questionnaire-36 items, version 2 (SF-36v2) Physical Component Score (PCS) at 6 months after randomisation. Secondary outcomes included other measures of health outcome [Measure Yourself Medical Outcomes Profile, European Quality of Life-5 Dimensions (EuroQol health utility measure, EQ-5D), global improvement, response to treatment], wait for treatment, time lost from work and usual activities, patient satisfaction. Data were collected by postal questionnaires at baseline, 6 weeks and 6 months, and from routine records by researchers blind to allocation.

RESULTS

A total of 1506 patients were allocated to PhysioDirect and 743 to usual care. Patients allocated to PhysioDirect had a shorter wait for treatment than those allocated to usual care [median 7 days vs 34 days; arm-time ratio 0.32, 95% confidence interval (CI) 0.29 to 0.35] and had fewer non-attended face-to-face appointments [incidence rate ratio 0.55 (95% CI 0.41 to 0.73)]. The primary outcome at 6 months' follow-up was equivalent between PhysioDirect and usual care [mean PCS 43.50 vs 44.18, adjusted difference in means -0.01 (95% CI -0.80 to 0.79)]. The secondary measures of health outcome all demonstrated equivalence at 6 months, with slightly greater improvement in the PhysioDirect arm at 6 weeks' follow-up. Patients were equally satisfied with access to care but slightly less satisfied overall with PhysioDirect compared with usual care. NHS costs (physiotherapy plus other relevant NHS costs) per patient were similar in the two arms [PhysioDirect £ 198.98 vs usual care £ 179.68, difference in means £ 19.30 (95% CI -£ 37.60 to £ 76.19)], while QALYs gained were also similar [difference in means 0.007 (95% CI -0.003 to 0.016)]. Incremental cost per QALY gained was £ 2889. The probability that PhysioDirect was cost-effective at a £ 20,000 willingness-to-pay threshold was 88%. These conclusions about cost-effectiveness were robust to sensitivity analyses. There was no evidence of difference between trial arms in cost to patients or value of lost production. No adverse events were detected.

CONCLUSIONS

Providing physiotherapy via PhysioDirect is equally clinically effective compared with usual waiting list-based care, provides faster access to treatment, appears to be safe, and is broadly acceptable to patients. PhysioDirect is probably cost-effective compared with usual care.

Preferences for aspects of a dermatology consultation

BACKGROUND

General practitioners with special interests (GPSIs) are increasingly being used to provide dermatology services in the U.K. Little is known about U.K. dermatology patient attitudes to proposed variations in secondary care service delivery or the values they attach to aspects of the care they receive.

OBJECTIVES

To quantify preferences for different attributes of care within dermatology secondary care services.

METHODS

Attributes of care that are important to dermatology patients were derived using in-depth qualitative interviews with 19 patients at different points in the care pathway. A discrete choice experiment using 'best-worst scaling' was sent by post to 119 patients referred to secondary care dermatology services and suitable for GPSI care who had agreed to participate in research.

RESULTS

Four attributes were derived from the qualitative work: waiting, expertise, thorough care and convenience. For the discrete choice experiment, 99 patients returned questionnaires, 93 of which contained sufficient data for analysis. All attributes were found to be quantitatively important. The attribute of greatest importance was expertise of the doctor, while waiting time was of least importance. Respondents were willing to wait longer than the current 3 months maximum to receive care that was thorough, 2.1 months to see a team led by an expert and 1.3 months to attend a consultation that is easy to get to.

CONCLUSIONS

Although the need to reduce outpatient waiting times is a key policy driver behind the expansion of GPSI services, this does not appear to be the most important issue for patients. The thoroughness with which the consultation is provided and the expertise of the clinician seen are higher priorities.

Who wants to know if their care is rationed? Views of citizens and service informants

OBJECTIVE

To explore the views of citizens and service informants about whether they would want to know about any rationing of their own health care.

DESIGN

In-depth interviews using a semistructured schedule. Data were analysed using the methods of constant comparison.

SETTING AND PARTICIPANTS

Citizens and service informants.

MAIN VARIABLES STUDIED

Issues around health care rationing were explored within the context of the United Kingdom health care system.

RESULTS

The views of citizens and service informants were very similar in terms of whether they, personally, wanted to know about any rationing of their own care, with the vast majority wanting to be given this information. Informants were also similar in terms of their reasons for wanting to know about rationing: to be given a 'good explanation' to enable them to judge whether the decision made had been correct; and to enable them to change the decision if necessary, either through protest or payment. Many informants suggested that they would indeed be likely to react either by challenging the decision or by paying for care.

CONCLUSIONS

The findings suggest that policies to be open with people about the rationing of care would be welcomed, but also indicate that if protest follows such openness, it may be difficult for the health service to cope with greater explicitness. Further research is needed among patient groups actually facing this situation.

Directly observed treatment for multidrug-resistant tuberculosis: an economic evaluation in the United States of America and South Africa

OBJECTIVE

To estimate the cost-effectiveness of directly observed treatment compared to conventional therapy in reducing the spread of multidrug-resistant tuberculosis, for an industrialised country (represented by the United States of America) and a developing country (South Africa).

METHODS

Monte Carlo analysis using published data on probability, cost and health impact.

RESULTS

In both countries, directly observed treatment is the dominant strategy, yielding cost savings and improved health outcomes. Cost savings for directly observed treatment relative to conventional therapy become more significant as more expensive second-line drugs are used in treatments.

CONCLUSIONS

The cost-effectiveness of directly observed treatment relative to conventional therapy is demonstrated for both the USA and South Africa. Cost savings are more pronounced (especially for South Africa) as the likelihood of multidrug-resistant tuberculosis increases and more expensive second-line therapies are used. Given that health care resources are more severely constrained in developing countries, the data contained in this study are useful in guiding the design of policies for the effective management of multidrug-resistant tuberculosis in settings with limited resources.

Citizens, their agents and health care rationing: an exploratory study using qualitative methods

This paper considers the application of the theoretical notion of a principal-agent relationship to societal health care decision making. Current literature sheds little light upon whether a citizen-agent relationship exists in health care, with ambiguity about whether citizens want agents to make rationing decisions on their behalf, and if so, who these societal agents might be. A qualitative approach, using semi-structured interviews as the main instrument of data collection and analysis by constant comparison, was used to explore these issues with groups of both citizens and their potential agents. The findings of the research suggest that citizens vary considerably in the extent to which they want to be directly involved in making rationing decisions. Important influences on this issue appear to be knowledge and experience, objectivity and the potential distress that denying care may cause. Agents, in contrast, view citizens as needing agents to make decisions for them and suggest that it is primarily the health authority's role to act in this capacity. It is, however, apparent that the citizen-agent relationship in health care is both imperfect and complex, with final decisions resulting from the interaction between the utility functions of the various actors in the health care system. In practice a system of equivocation can be envisaged in which different groups collude as they attempt to avoid the disutility associated with denying care, with the consequence that the impact of decisions taken on an explicitly societal or citizen basis may be relatively small.

How great a burden does early discharge to hospital-at-home impose on carers? A randomized controlled trial

OBJECTIVE

to assess the effects of an early discharge hospital-at-home scheme on self-reported carer strain and quality of life.

DESIGN

a randomized controlled trial

SETTING

Bristol, UK.

SUBJECTS

133 carers of patients receiving either early discharge from hospital to hospital-at-home (n = 93) care or usual hospital care and discharge (n = 40).

OUTCOME MEASURES

modified 12-item Carer Strain Index, COOP-WONCA charts and EuroQol EQ-5D at 4 weeks and 3 months post-randomization.

RESULTS

the mean age of carers was 65 years; 56% were women. There were no marked differences between the groups in any of the outcomes used at either 4-week or 3-month follow-up.

CONCLUSION

there was no evidence of increased self-reported burden imposed on carers of patients discharged early from hospital. Decisions on the implementation of hospital-at-home schemes should be influenced by considerations of cost and effectiveness rather than effects on carers. The effects on carers may, however, differ for other forms of home-based care.

Inter-rater reliability of the Barthel ADL index: how does a researcher compare to a nurse?

OBJECTIVES

To investigate whether a nonclinical research assistant, using standardized scoring criteria, can reliably administer the Barthel Activities of Daily Living (ADL) Index in a sample of elderly inpatients.

DESIGN

Paired comparison of nurse and nonclinical research assistant Barthel Index assessments.

SETTING

Acute hospital wards from two hospitals in a UK Healthcare Trust, with a catchment population of approximately 224,000 people.

METHODS

A consecutive sample of 94 elderly patients with a variety of medical problems.

MAIN OUTCOME MEASURES

Barthel ADL Index, Folstein Mini-Mental Status Examination.

RESULTS

Whilst the inter-rater reliability of the Barthel Index was within acceptable boundaries, two items out of ten had only fair agreement and low crude agreement (transfer and dressing) on Cohen's kappa scores.

CONCLUSIONS

Depending on the differences observed in any particular context, the Barthel Index can be applied with reasonable reliability by nonclinical staff applying the standardized scoring criteria. It should be noted, however, that the kappa coefficients between clinical and nonclinical assessors tend to be lower than those found when comparing two clinically trained assessors in previous research.

Conceptual and practical difficulties with the economic evaluation of health services developments

Five recent economic evaluations comparing hospital at home schemes with acute hospital care faced remarkably similar problems. This paper outlines these problems and considers what strategies can be derived from these experiences, which will be relevant to economic evaluations of other aspects of the organisation of care, particularly those crossing the interfaces between primary and secondary health care or the interface between health and social services. The difficulties experienced can be divided into conceptual and practical problems. Conceptual problems were primarily associated with issues of context and related to the choice of comparator, capacity constraints and size of schemes, and the choice between a short or a long run perspective. Practical problems were connected with the time at which schemes were evaluated, the type of clinical study alongside which studies were conducted and the types of data available for use in the analysis. Strategies which can be pursued in conducting economic evaluations of organisational change include giving greater attention to conceptual and hence contextual problems as well as reporting these contextual issues in detail, accepting the need for repeated economic evaluations as organisational changes become more widespread and considering carefully the clinical study design where economic evaluations of organisational change are conducted alongside. These strategies are of importance not just to those conducting economic evaluations but also to those funding appraisals of changes in the organisation of care. Use of different strategies such as those suggested here should be evaluated.

The appropriate uses of qualitative methods in health economics

Ontology, epistemology and methodology are not subjects frequently discussed in health economics, yet they are of great relevance to the question of how, or whether, to use qualitative methods as a means of examining certain issues. The paper discusses the nature of enquiry in health economics and then details the nature of qualitative methods and the constructivist philosophy with which they are most commonly associated. The paper continues by examining different areas in the study of economics: neo-classical positive economics, alternative approaches to explanatory economics and normative welfare economics. For each area the philosophical approach is outlined as are the areas of research interest. Appropriate roles for qualitative methods within these philosophical approaches are then suggested. The paper concludes by warning that health economists should not use qualitative methods naively. They must be aware of the potential difficulties: both of inadvertently ending up outside the intended research philosophy and of conducting research which is accepted by neither economists nor qualitative researchers. If, however, health economists are aware of ontological, epistemological and methodological issues, they can make an informed decision about the appropriateness of qualitative methods in their research and thereby potentially enhance their ability to answer the questions in which they are interested.

Randomised controlled trial comparing effectiveness and acceptability of an early discharge, hospital at home scheme with acute hospital care

OBJECTIVE

To compare effectiveness and acceptability of early discharge to a hospital at home scheme with that of routine discharge from acute hospital.

DESIGN

Pragmatic randomised controlled trial.

SETTING

Acute hospital wards and community in north of Bristol, with a catchment population of about 224 000 people.

SUBJECTS

241 hospitalised but medically stable elderly patients who fulfilled criteria for early discharge to hospital at home scheme and who consented to participate.

INTERVENTIONS

Patients' received hospital at home care or routine hospital care.

MAIN OUTCOME MEASURES

Patients' quality of life, satisfaction, and physical functioning assessed at 4 weeks and 3 months after randomisation to treatment; length of stay in hospital and in hospital at home scheme after randomisation; mortality at 3 months.

RESULTS

There were no significant differences in patient mortality, quality of life, and physical functioning between the two arms of the trial at 4 weeks or 3 months. Only one of 11 measures of patient satisfaction was significantly different: hospital at home patients perceived higher levels of involvement in decisions. Length of stay for those receiving routine hospital care was 62% (95% confidence interval 51% to 75%) of length of stay in hospital at home scheme.

CONCLUSIONS

The early discharge hospital at home scheme was similar to routine hospital discharge in terms of effectiveness and acceptability. Increased length of stay associated with the scheme must be interpreted with caution because of different organisational characteristics of the services.

Hospital at home or acute hospital care? A cost minimisation analysis

OBJECTIVE

To compare, from the viewpoints of the NHS and social services and of patients, the costs associated with early discharge to a hospital at home scheme and those associated with continued care in an acute hospital.

DESIGN

Cost minimisation analysis.

SETTING

Acute hospital wards and the community in the north of Bristol (population about 224 000).

SUBJECTS

241 hospitalised but medically stable elderly patients who fulfilled the criteria for early discharge to a hospital at home scheme and who consented to participate.

MAIN OUTCOME MEASURES

Costs to the NHS, social services, and patients over the 3 months after randomisation.

RESULTS

The mean cost for hospital at home patients over the 3 months was 2516 pounds, whereas that for hospital patients was 3292 pounds. Under all the assumptions used in the sensitivity analysis, the cost of hospital at home care was less than that of hospital care. Only when hospital costs were assumed to be less than 50% of those used in the initial analysis was the difference equivocal.

CONCLUSIONS

The hospital at home scheme is less costly than care in the acute hospital. These results may be generalisable to schemes of similar size and scope, operating in a similar context of rising acute admissions.

Controlling antimicrobial resistance: a proposed transferable permit market

Resistance to antimicrobials results in those antimicrobials becoming ineffective in treating common bacterial infections. To prevent the spread of such resistance the use of antimicrobials requires control. The authors have previously argued that use of regulation or charges to control resistance would not be efficient. Regulation will not account for different marginal costs of reducing antimicrobial prescription amongst GPs, and charges, although based on sound economic concepts, are based on an unrealistic amount of required information. It was therefore argued that a system of tradable permits, by combining the targets of regulation and the market flexibility of charges, would achieve control more efficiently than simple regulation or charges. In this paper the authors progress this proposed policy by considering various important issues which arise when designing such a tradable permit system for antimicrobials. The paper does not provide an exhaustive plan enabling a blueprint for such a market to be designed, but a proposal which may be used as platform for further specific development of such an initiative to deal with resistance.

An economic perspective on policy to reduce antimicrobial resistance

Resistance to antimicrobial drugs is increasing worldwide. This resistance is, at least in part, associated with high antimicrobial usage. Despite increasing awareness, economists (and policy analysts more generally) have paid little attention to the problem. In this paper antimicrobial resistance is conceptualised as a negative externality associated with the consumption of antimicrobials and is set within the broader context of the costs and benefits associated with antimicrobial usage. It is difficult to determine the overall impact of attempting to reduce resistance, given the extremely limited ability to model the epidemiology of resistant and sensitive micro-organisms. It is assumed for the purposes of the paper, however, that dealing with resistance by reducting antimicrobial usage would lead to a positive societal benefit. Three policy options traditionally associated with environmental economics (regulation, permits and charges) are examined in relation to their potential ability to impact upon the problem of resistance. The primary care sector of the U.K.'s National Health Service provides the context for this examination. Simple application of these policies to health care is likely to be problematic, with difficulties resulting particularly from the potential reduction in clinical freedom to prescribe when appropriate, and from the desire for equity in health care provision. The paper tentatively concludes that permits could offer the best policy response to antimicrobial resistance, with the caveat that empirical research is needed to develop the most practical and efficient system. This research must be conducted alongside the required epidemiological research.

Use of the EuroQoL among elderly acute care patients

The assessment of the validity and reliability of generic quality of life (QoL) instruments among elderly patient groups has tended to lag behind such assessments in general populations, yet it is an important methodological issue. This paper presents the findings from a study of the use of the EuroQoL among an elderly acute care patient group, focusing particularly on the ability to self-complete, construct validity and sensitivity to change. Two hundred and fourteen UK patients aged 65 years and over, participating in a randomized controlled trial comparing hospital at home and routine hospital care were asked to complete the EuroQoL and a number of other instruments at randomization and at 4 week and 3 month follow-ups. The inability to self-complete the EuroQol was found to be strongly related to both increased age and reduced cognitive function (p < 0.0001). From logistic regression, the expected probability of an acute care patient requiring interview administration at age 65 years is 11%, at age 75 years is 37% and at age 85 years is 73%. The relationships with age and limiting long-standing illness/disability were weaker than expected, but the results obtained from the EuroQoL were highly correlated with those from both the Barthel Index and the COOP-WONCA charts where this was anticipated. Preliminary evidence of sensitivity to change was found from descriptive statistics of the changes in scores for four specific subgroups of patients, but the small numbers and high variability in each sub-sample means that this should be interpreted with caution. The most important issue arising from the research concerns the impact of age on the ability to self-complete the EuroQoL questionnaire. It is argued that this research points to the need for rigorous studies (such as randomized controlled trials) to assess the impact of the format of administration of the EuroQoL on the scores obtained.

Effect of varying the time frame for COOP-WONCA functional health status charts: a nested randomised controlled trial in Bristol, UK

STUDY OBJECTIVES

To investigate whether changing the stated time frame for COOP-WONCA charts has any effect on responses. Specifically, to assess the effect of attempting to avoid the situation where the time frame crosses the onset of an acute episode.

DESIGN

A randomised controlled trial of two time frames, nested within a main trial comparing early discharge with a hospital at home scheme against routine discharge policy. The time frames compared were the standard two weeks (four for the pain chart) and a shorter period of 48 hours for all seven charts.

SETTING

Acute hospital wards in Frenchay Healthcare Trust and the Avon Orthopaedic Centre in Bristol.

PARTICIPANTS

Patients entered into the main trial, who were medically stable, in need of continued rehabilitative care but suitable for discharge to hospital at home.

MAIN RESULTS

A total of 200 patients were randomised, 106 to the shorter time frame, 94 to the standard charts. No clear differences were observed between the two groups for the proportion failing to self complete the charts. For the (seven) chart scores, only pain was statistically significantly different between the time frames (Mann-Whitney p = 0.0085; proportion reporting moderate or severe pain 19% higher in the standard group, 95% confidence intervals 5% to 33%). For both this chart and that for change in health, however, there was evidence of greater differences between the versions of the chart among those admitted more recently (p values for relevant interactions 0.004 and < or = 0.001 respectively).

CONCLUSIONS

While the present findings give some support for the wide applicability of the standard version, there is sufficient evidence here to indicate that the time frame may influence the results, particularly for patients with a recent acute episode. In the absence of further data, then, it would seem prudent to consider a shorter time frame for such patients, especially if the aim is to assess current health status or to measure changes over a comparatively short period of time, or both.

Diagnosis, management and screening of early localised prostate cancer

The incidence of prostate cancer is rising worldwide, caused mainly by demographic factors, particularly the increasingly elderly population and, more importantly, the increasing number of cases identified following prostate specific antigen (PSA) testing. It is commonly quoted that many more men die with prostate cancer than of it. Autopsy/post-mortem studies show that while a very high proportion of elderly men have histological evidence of the disease, a much smaller proportion develop clinically apparent cancer. The natural history of prostate cancer is poorly understood, but progression appears to be related to stage and grade of tumour. Prostate cancer can be diagnosed by digital rectal examination (DRE), serum PSA test, and/or transrectal ultrasound (TRUS), with confirmation by biopsy. Each test identifies a proportion of cancers, with higher rates of detection when they are used in combination. The tests are also used to determine which tumours are localised within the prostate and are, thus, potentially treatable. Unfortunately, clinical staging is unreliable, with approximately one half of all tumours upstaged following surgery. Three major treatment options are available for localised prostate cancer: radical prostatectomy, radical radiotherapy and conservative management (involving monitoring and treatment of symptoms). Although radical treatment rates are rising, good quality evidence concerning their comparative effectiveness and cost-effectiveness is lacking. Observational studies of highly selected patient groups suggests that there may be a slightly lower mortality rate following radical treatments compared with conservative management, but there has been very little research into treatment complications and quality of life of men after any of the treatments. In the past, investigations of prostate cancer were reserved largely for patients exhibiting symptoms, but the introduction of the PSA test has opened up the possibility of screening healthy men for the disease. Observational studies suggest that DRE and PSA, combined with TRUS and biopsy, can identify localised prostate cancer in 3-5% of men, although the tests do result in a number of false positives and negatives. Major questions remain concerning the natural history of the disease, potential costs (financial, social and psychological) of a screening programme, and the effectiveness and cost-effectiveness of treatments for localised disease. The lack of good quality data and the strength of these concerns means that population screening for prostate cancer cannot be recommended.

Using the ICSOoL to measure the impact of lower urinary tract symptoms on quality of life: evidence from the ICS-'BPH' Study. International Continence Society--Benign Prostatic Hyperplasia

OBJECTIVE

To present and describe the validity and reliability of the International Continence Society-Benign Prostatic Hyperplasia study quality-of-life (ICSQoL) instrument, a new set of questions to assess the impact of lower urinary tract symptoms (LUTS) on quality of life (QoL) in middle-aged and elderly men.

PATIENTS AND METHODS

The study comprised 1271 consecutive men over the age of 45 years, attending urology departments in 12 countries, with LUTS and possible benign prostatic obstruction who were recruited to the ICS-'BPH' study (the clinic group); 423 ambulant men were recruited from a general practice in the UK to provide a community group. Each individual completed the ICS-'BPH' study questionnaire which includes six items addressing general and specific aspects of QoL (the ICSQoL). Content and construct validity were assessed by interviews with patients and by testing hypotheses within the study groups, e.g. the relationships with age, individual LUTS (as measured on the ICSmale questionnaire) and generic health status, as measured by the Short Form (SF-36) and EuroQol instruments. Reliability was assessed by measures of internal consistency and a test-retest analysis.

RESULTS

The ICSQoL items were easily understood by patients, were completed with low levels of missing data, and address some (but not all) concerns about the impact of LUTS on QoL. The ICSQoL items have good construct validity, showing expected differences between community and clinic samples, and expected relationships with each other and individual LUTS. Items had good test-retest reliability, but their internal consistency was poor, confirming that ICSQoL questions should not be combined into a score. General ICSQoL items were closely related with most domains of the SF-36 and the EuroQol.

CONCLUSION

ICSQoL items may be used individually or as a group in research studies or in clinical practice.

Economics of thromboprophylaxis in total hip replacement surgery

In 1997, 50,000 hip replacements will be performed in the UK, and over 1 million worldwide. Venous thromboembolism is the most frequent serious complication following joint replacement; its effective and economic management is essential. Antithrombotic prophylaxis can be used to reduce the incidence of venous thromboembolic disease, which presents as either deep vein thrombosis or pulmonary embolism. A number of published studies have shown that prophylaxis against venous thromboembolism is financially beneficial in terms of reduced diagnostic and treatment costs. Cost-effectiveness studies have provided a comparison of the costs and consequences resulting from alternative prophylactic programmes. This article reviews the epidemiology of venous thromboembolism after total hip replacement, prophylaxis against it and a model for cost-effectiveness analysis. Its aim is to highlight inadequacies in the available data and areas of uncertainty within the model that require further research. Pharmacoeconomic studies published to date have all used a similar framework to allow prophylactic options to be compared. However, assumptions made about the frequency of clinical disease have varied widely between studies. This degree of uncertainty calls into question the validity of reported incremental cost savings between treatments. Some studies have also failed to address the cost of complications resulting from the prophylactic method under consideration. Future studies must carefully consider the validity of their models, understand the limitations on current knowledge of outcome rates, and carefully consider all outcomes (both beneficial and detrimental) that result from the intervention.

A randomized controlled trial of antibiotics on symptom resolution in patients presenting to their general practitioner with a sore throat

BACKGROUND

Sore throat is a common symptom presented to general practitioners (GPs), and there remains controversy about the appropriate use of antibiotics.

AIM

To compare, in a randomized controlled trial, the effectiveness of penicillin, cefixime and placebo on symptom resolution in patients presenting with a sore throat in general practice.

METHOD

Twenty-two GPs in Avon recruited 154 patients, aged 16-60 years, presenting to their GP with a sore throat, and for whom the GP would normally prescribe an antibiotic. Patients were randomized to one of three groups: penicillin V 250 mg four times a day; cefixime 200 mg daily; and placebo. Each was prescribed for five days. The main outcome measures were a diary of symptom resolution over seven days and eradication of group A beta-haemolytic streptococcus (GABHS).

RESULTS

Of the 103 (67%) patients who completed symptom diaries, 40 were allocated to receive penicillin, 29 cefixime and 34 placebo. In the analysis including all patients, symptom resolution was greater by day 3 in the cefixime group than in the placebo group. Penicillin did not improve symptom resolution by day 3 compared with placebo, and cefixime was not statistically significantly different from penicillin. There were significant differences in the proportion of patients using analgesia at day 3, with the proportion being lowest in the cefixime group. The results for the subgroup of patients without GABHS were similar to those for all patients; in particular, the only statistically significant difference was between cefixime and placebo. Although numbers were too small for statistical significance, among patients with GABHS the effects of penicillin and cefixime were similarly raised in relation to placebo.

CONCLUSION

Compared with placebo, cefixime can improve the rate of resolution of symptoms in patients with a sore throat who are selected for antibiotic treatment by their GP. The unexpected finding that cefixime was of benefit compared with placebo for patients without GABHS suggests that bacteria other than GABHS may be important in the pathogenesis of sore throat.

Comparing costs of monitoring glaucoma patients: hospital ophthalmologists versus community optometrists

OBJECTIVES

To compare the costs of monitoring stable glaucoma patients by community optometrists and hospital ophthalmologists.

METHODS

A cost analysis was conducted alongside a randomised controlled trial which compared the accuracy and acceptability of measurement in each form of care. The viewpoints of the health service and of patients were considered. Costs were assessed using a number of different methods. Sensitivity analysis was conducted for key variables.

RESULTS

The baseline analysis reflected heavily the different length of time between follow-up in the two arms of the trial (10 months (average) for hospital, 6 months for optometrists). It showed annual cost per patient for hospital ophthalmologists varied from 14.50 pounds to 59.95 pounds, and community optometrist costs varied from 68.98 pounds to 108.98 pounds. Assuming a 6-month follow-up interval for the hospital ophthalmologists, costs varied from 24.16 pounds to 99.92 pounds.

CONCLUSIONS

Recommendations about the least costly form of follow-up must depend on the context in which the decision is being taken and the scale of change envisaged. If the aim is to recoup resources from hospitals in order to pay for monitoring in the community, community monitoring is unlikely to be the least costly option.

Superbugs: should antimicrobial resistance be included as a cost in economic evaluation?

This paper argues that increasing resistance to antimicrobials is an important social externality that has not been captured at the level of economic appraisal. The paper explicitly considers reasons why the externality of antimicrobial resistance has not generally been included as a cost in economic evaluations comparing management strategies for infectious diseases. Four reasons are considered: first, that the absolute cost of antimicrobial resistance is too small to be worth including; second, that there is an implicit discounting of the costs of antimicrobial resistance on the basis of time preference which makes the cost too small to be worth including; third, that there is an implicit discounting of the costs of antimicrobial resistance on the basis of uncertainty which makes the cost too small to be worth including; and fourth, that the costs are too difficult to measure. Although there does not appear to be methodological justification for excluding the costs of antimicrobial resistance, it seems likely that, because of the practical difficulties associated with measuring these costs, they will continue to be ignored. The paper concludes with a discussion of the applicability of standard policy responses used to deal with externalities in other areas of welfare economics.

Appropriateness versus efficiency: the economics of utilisation review

The aim of routine utilisation review is to identify patients who are inappropriately placed in an acute unit and who could be alternatively treated in a lower technology facility. Utilisation review was designed as a means of cost control in the USA. but problems with rising emergency admissions and consequent acute bed shortages in the UK have led to a substantial and growing interest in the concept of appropriateness and in the development of utilisation review instruments. Appropriate care is not necessarily the same as efficient care, however, and inappropriate care could potentially be more cost-effective than the alternative. This will depend on, first, whether the design of utilisation review instruments is such that they will encourage efficiency, and second. whether efficiency objectives would be met by the application of utilisation review in the context of the UK health care system. The first issue is discussed in relation to the effectiveness of alternative forms of care. The second is discussed in relation to the potential for reductions in cost, the issue of institutional resistance in the UK, and the validity of utilisation review instruments. The paper concludes that the potential impact of utilisation review on technical efficiency in the UK is ambiguous and questions its purpose in the National Health Service.

Factors associated with inappropriate emergency hospital admission in the UK

This paper reports an attempt to assess the factors associated with inappropriate acute hospital admission using the technique of logistic regression. Data were obtained from two separate studies of acute hospital utilization in south-west England, conducted between 1992 and 1994. The appropriateness of admission was assessed using explicit standardized criteria in the form of the intensity-severity-discharge review system with adult criteria (ISD-A). Up to 19 explanatory variables were available for the analyses. These variables were modelled for each centre separately, using logistic regression to produce final sets of factors independently related to the appropriateness of admission. For one centre, the final model contained age/ specialty and use of community services. For the other, the final model contained two measures of health status on admission-coping failure and admission with stroke. It is concluded that the complex interplay between the characteristics of patients, referrers, alternative forms of care and the acute hospital may result in quite different types of inappropriate admissions in different locations.

Alternatives to hospital care: what are they and who should decide?

OBJECTIVE

To examine potential for alternatives to care in hospitals for acute admissions, and to compare the decisions about these alternatives made by clinicians with different backgrounds.

DESIGN

Standardised tool was used to identify patients who could potentially be treated in an alternative form of care. Information about such patients was assessed by three panels of clinicians: general practitioners without experience of general practitioner beds, general practitioners with experience of general practitioner beds, and consultants.

SETTING

One hospital for acute admissions in a rural area of the South and West region of England.

SUBJECTS

Of 620 patients admitted to specialties of general medicine and care of the elderly, details of 112 were assessed by panels.

MAIN OUTCOME MEASURES

Proportion of hospitalised patients who could have received alternative care and identification of most appropriate alternative form of care.

RESULTS

Both general practitioner panels estimated that between 51 and 89 of the hospitalised patients could have received alternative care (equivalent to 8-14% of all admissions). Consultants estimated that between 25 and 55 patients could have had alternative care (5.5-9% of all admissions). General practitioner bed and urgent outpatient appointment were the main alternatives chosen by all three panels.

CONCLUSION

About 10% of admissions to general hospital might be suitable for alternative forms of care. Doctors with different backgrounds made similar overall assessments of most appropriate forms of care.

Appropriateness of hospital utilization. The validity and reliability of the Intensity-Severity-Discharge Review System in a United Kingdom acute hospital setting

Assessing the appropriateness of hospital utilization in the United Kingdom may yield practical solutions to problems faced by both purchasers and providers of health care in the National Health Service. It is, however, essential that such assessment is based on a method that is both valid and reliable--in particular, valid in the context in which it is applied. Whereas American methods for the assessment of appropriateness have been shown to be valid in the United States, it is pertinent to question whether the application of such methods to the National Health Service also is valid given the different circumstances, both cultural and financial, under which health care is provided. A study of the appropriateness of admission and hospital stay for a sample of admissions to a large acute hospital in the United Kingdom was carried out, and the assessment of appropriateness was made using the Intensity-Severity-Discharge Review System with Adult criteria (ISD-A). The validity and reliability of using the ISD-A for assessing hospital utilization in the United Kingdom was evaluated. The ISD-A was found to have high reliability and to be valid for assessing appropriateness in the United Kingdom when a full range of alternative forms of care are presumed to be available. It was not found to be valid currently, therefore, for routine assessment of hospital utilization within the National Health Service, when alternatives often are not available.

The cost of monitoring glaucoma patients by community optometrists

Glaucoma patients are currently undergoing monitoring by community based optometrists as part of a randomised controlled trial of shared care. As part of this trial, the costs of monitoring these patients by community optometrists are being calculated. Data were obtained from eight practices for the 1993-1994 financial year. The average 'full' cost of a 40 min appointment was calculated as epsilon 31.56 pounds. The average number of unbooked appointments for the month of October 1994 was 16 per practice, which equated to 12, 40 min appointments. Once the number of unbooked appointments was surpassed for each practice, an average opportunity cost of epsilon 54.00 pounds was experienced per appointment. The participating optometrists were willing to accept a minimum fee of epsilon 26.03 pounds for a small number of patient assessments but this rose to epsilon 43.16 pounds for up to 100 glaucoma patients seen per annum.

The hospital admissions study in England: are there alternatives to emergency hospital admission?

STUDY OBJECTIVE

To assess the potential for substituting alternative forms of care for admission to an acute hospital in particular groups of patients.

DESIGN

A screening tool, the intensity-severity-discharge review system with adult criteria (ISD-A), developed for hospital utilisation review in the USA, was used in a cohort of hospital admissions to identify a group of patients who could potentially have been treated outside the acute hospital. These patients were further assessed by a panel of general practitioners (GPs) to determine the most appropriate alternative form of care. A cost analysis was performed on the results obtained.

SETTING

General medicine and geriatric specialties in one acute hospital in the south western region.

PATIENTS

Patients comprised a sample of 701 admitted to general medical and geriatric specialties.

MAIN RESULTS

The screening tool identified 19.7% of admissions for whom there was potential for treatment outside the acute hospital. Assessment by the GP panel reduced this potential to between 9.8% and 15.0% of emergency admissions. The alternatives most frequently identified as "most appropriate" were the community hospital/GP bed and the urgent outpatient assessment (within either 24 or 48 hours). Potential resource savings based on the average cost were relatively small. This potential seemed to be greater for the alternative of the urgent outpatient assessment.

CONCLUSIONS

Potential exists for treating a proportion of patients in lower intensity alternatives to the acute hospital. If this potential were exploited few resource savings would occur.

The role of economic evaluation in setting priorities for elective surgery

Problems with waiting lists have long affected the National Health Service. The priority given by clinicians to the elective surgery conditions usually found on waiting lists is low, but the publicity surrounding the waiting lists ensures that the priority accorded elective surgery in the political arena is much higher. Waiting list initiatives have provided additional resources for the purpose of reducing the number of patients waiting for elective surgery. It is suggested that economic evaluation should form one of a package of tools used by those setting priorities within elective surgery, but that the evidence provided by previously conducted economic evaluations of elective surgery is not of sufficient quality for purchasing authorities to use as a basis for priority setting.

Reprocessing data to form QALYs

OBJECTIVES

To determine whether reprocessing data from published sources into quality adjusted life years (QALYs), as recommended in The QALY Toolkit, is a useful method of helping purchasing authorities to determine the most cost effective pattern of care to buy for their populations.

SETTING

United Kingdom.

DESIGN

The method was tested for six elective surgical conditions; data from published studies were reprocessed into the Rosser index, to obtain values for change in quality of life. These were then used to form QALYs. A small validation exercise was carried out.

MAIN OUTCOME MEASURES

QALYs formed from the Rosser index.

RESULTS

Published data could not be found for three interventions (cataract surgery, inguinal hernia repair, varicose vein surgery). For the remainder (prostatectomy, hip replacement, and knee replacement) data were found which could be reprocessed to form QALYs, though it was often hard to compare data from different studies and many assumptions had to be made.

CONCLUSION

The value of QALY results obtained by this method is questionable, given the large number of assumptions which had to be made. For many interventions published data are unlikely to be available.