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Biomedical subjects

A McGuire

Publications and source records attributed to A McGuire.

At least 19 recordsLinked to original sources
PubMed2001

Cost-utility of enoxaparin compared with unfractionated heparin in unstable coronary artery disease.

BACKGROUND: Low molecular weight heparins hold several advantages over unfractionated heparin including convenience of administration. Enoxaparin is one such heparin licensed in the UK for use in unstable coronary artery disease (unstable stable angina and non-Q wave myocardial infarction). In these patients, two large randomised controlled trials and their meta-analysis showed small benefits for enoxaparin over unfractionated heparin at 30-43 days and potentially at one year. We found no relevant published full economic evaluations, only cost studies, one of which was conducted in the UK. The other studies, from the US, Canada and France, are difficult to interpret since their resource use and costs may not reflect UK practice. METHODS: We aimed to compare the benefits and costs of short-term treatment (two to eight days) with enoxaparin and unfractionated heparin in unstable coronary artery disease. We used published data sources to estimate the incremental cost per quality adjusted life year (QALY), adopting a NHS perspective and using 1998 prices. RESULTS: The base case was a 0.013 QALY gain and net cost saving of 317 pounds sterling per person treated with enoxaparin instead of unfractionated heparin. All but one sensitivity analysis showed net savings and QALY gains, the exception (the worst case) being a cost per QALY of 3,305 pounds sterling. Best cases were a 495 pounds sterling saving and 0.013 QALY gain, or a 317 pounds sterling saving and 0.014 QALY gain per person. CONCLUSIONS: Enoxaparin appears cost saving compared with unfractionated heparin in patients with unstable coronary artery disease. However, cost implications depend on local revascularisation practice.

Angina, Unstable↗
PubMed2001

Postoperative adhesions: ten-year follow-up of 12,584 patients undergoing lower abdominal surgery.

PURPOSE: Postoperative adhesions are a significant problem after colorectal surgery. However, the basic epidemiology and clinical burden are unknown. The Surgical and Clinical Adhesions Research Study has investigated the scale of the problem in a population of 5 million. METHODS: Validated data from the Scottish National Health Service Medical Record Linkage Database were used to define a cohort of 12,584 patients undergoing open lower abdominal surgery in 1986. Readmissions for potential adhesion-related disease in the subsequent ten years were analyzed. The methodology was conservative in interpreting adhesion-related disease. RESULTS: In the study cohort 32.6 percent of patients were readmitted a mean of 2.2 times in the subsequent ten years for a potential adhesion-related problem. Although 25.4 percent of readmissions were in the first postoperative year, they continued steadily throughout the study period. After open lower abdominal surgery 7.3 percent (643) of readmissions (8,861) were directly related to adhesions. This varied according to operation site: colon (7.1 percent), rectum (8.8 percent), and small intestine (7.6 percent). The readmission rate was assessed to provide an indicator of relative risk of adhesion-related problems after initial surgery. The overall average rate of readmissions was 70.4 per 100 initial operations, with 5.1 directly related to adhesions. This rose to 116.4 and 116.5, respectively, after colonic or rectal surgery-with 8.2 and 10.3 directly related to adhesions. CONCLUSIONS: There is a high relative risk of adhesion-related problems after open lower abdominal surgery and a correspondingly high workload associated with these readmissions. This is influenced by the initial site of surgery, colon and rectum having both the greatest impact on workload and highest relative risk of directly adhesion-related problems. The study provides sound justification for improved adhesion prevention strategies.

Abdomen↗
PubMed2001

Assessment of quality of life in lung transplantation using a simple generic tool.

BACKGROUND: The EuroQol is a generic questionnaire developed to provide a simple method for assigning utility values to health. This study examines the applicability of the EuroQol to the measurement of quality of life in single, bilateral, and heart-lung transplantation. METHODS: A cross sectional study was performed in 87 patients awaiting lung transplantation and in 255 transplant recipients attending follow up clinics in four transplant units. RESULTS: In the waiting list group 61% reported extreme problems in at least one of the five EuroQol quality of life domains compared with 20% single lung recipients, 4% bilateral lung recipients, and 2% heart-lung recipients at 3 or more years after transplantation. The mean utility value of patients on the waiting list was 0.31. In comparison, utility values for recipients 3 years after transplantation were 0.61 for single, 0.82 for bilateral, and 0.87 for heart-lung transplants. The utility scores and health profiles of bilateral and heart-lung recipients were consistently superior to those of single lung recipients. Problems in all five domains were more frequent in single lung recipients. Subjective assessment with a visual analogue scale showed a similar trend. CONCLUSIONS: The EuroQol is a simple method of deriving a single utility value for quality of life and is responsive to changes after lung transplantation. It is worth considering as a means of monitoring quality of life after transplantation and as an index of quality of survival in research studies in solid organ transplantation. These data suggest that quality of life after transplantation of one lung is inferior to that after transplantation of two lungs.

Cross-Sectional Studies↗
PubMed2000

Cost effectiveness of an intensive blood glucose control policy in patients with type 2 diabetes: economic analysis alongside randomised controlled trial (UKPDS 41). United Kingdom Prospective Diabetes Study Group.

OBJECTIVE: To estimate the cost effectiveness of conventional versus intensive blood glucose control in patients with type 2 diabetes. DESIGN: Incremental cost effectiveness analysis alongside randomised controlled trial. SETTING: 23 UK hospital clinic based study centres. PARTICIPANTS: 3867 patients with newly diagnosed type 2 diabetes (mean age 53 years). INTERVENTIONS: Conventional (primarily diet) glucose control policy versus intensive control policy with a sulphonylurea or insulin. MAIN OUTCOME MEASURES: Incremental cost per event-free year gained within the trial period. RESULTS: Intensive glucose control increased trial treatment costs by pound 695 (95% confidence interval pound 555 to pound 836) per patient but reduced the cost of complications by pound 957 (pound 233 to pound 1681) compared with conventional management. If standard practice visit patterns were assumed rather than trial conditions, the incremental cost of intensive management was pound 478 (-pound 275 to pound 1232) per patient. The within trial event-free time gained in the intensive group was 0.60 (0.12 to 1.10) years and the lifetime gain 1.14 (0.69 to 1.61) years. The incremental cost per event-free year gained was pound 1166 (costs and effects discounted at 6% a year) and pound 563 (costs discounted at 6% a year and effects not discounted). CONCLUSIONS: Intensive blood glucose control in patients with type 2 diabetes significantly increased treatment costs but substantially reduced the cost of complications and increased the time free of complications.

Adult↗
PubMed2000

Establishing health state valuations for disease specific states: an example from heart disease.

This study considers the feasibility of defining a QALY from disease-specific data using the New York Heart Association (NYHA) classification of heart failure. The study derives health state values for the four different NYHA classifications of disease progression using the time trade-off (TTO) instrument associated with the five dimensional (EQ-5D) health state valuation method. Consistent mappings between the disease classification and the chosen QALY instrument are found. With this being the case, the assumption of constant proportionality, which is necessary to define the QALY as an acceptable measure of health related preferences, is considered. It is found that constant proportionality does not hold across the more severe health states, thus questioning the use of QALYs as representing cardinal preference structures.

Adult↗
PubMed2000

Centre-specific or average unit costs in multi-centre studies? Some theory and simulation.

Costing issues are increasingly being addressed in multi-centre studies. In this paper, two methods for collecting costing information are compared within a simulated clinical trial setting. One method estimates average treatment costs by applying unit costs averaged across treatment centres to centre-specific volumes of resource use. The second uses centre-specific information for both the unit costs and the resource volumes, and then averages across centres. Using a pre-specified production relation between the different volumes of resource use, and simulating changes in unit costs, it is shown that these two methods result in statistically different estimates of average treatment costs. This finding holds, regardless of the degree of substitutability between the resource volumes, except when considerable uncertainty surrounds treatment centre responses to relative changes in unit costs. The findings suggest that a more cautious approach should be adopted in the collection, calculation and interpretation of treatment costs in multi-centre studies.

Computer Simulation↗
PubMed2000

Where are the economic guidelines coming from?

Economic guidelines recommend methods that should be employed in conducting economic evaluations of healthcare programs. The nature of the efficiency or equity goal underpinning economic guidelines is unclear. What is also unclear is how the methods recommended in the guidelines are linked to the underlying efficiency or equity goal being targeted. If it is unclear what efficiency/equity objectives are being pursued, then it is unlikely that even full implementation of economic guidelines will improve resource allocation.

Cost Control↗
PubMed2000

Overview of the arthritis Cost Consequence Evaluation System (ACCES): a pharmacoeconomic model for celecoxib.

Pharmacoeconomic analyses have become useful and essential tools for health care decision makers who increasingly require such analyses prior to placing a drug on a national, regional or hospital formulary. Previous health economic models of non-steroidal anti-inflammatory drugs (NSAIDs) have been restricted to evaluating a narrow range of agents within specific health care delivery systems using medical information derived from homogeneous clinical trial data. This paper summarizes the Arthritis Cost Consequence Evaluation System (ACCES)--a pharmacoeconomic model that has been developed to predict and evaluate the costs and consequences associated with the use of celecoxib in patients with arthritis, compared with other NSAIDs and NSAIDs plus gastroprotective agents. The advantage of this model is that it can be customized to reflect local practice patterns, resource utilization and costs, as well as provide context-specific health economic information to a variety of providers and/or decision makers.

Aged↗
PubMed1999

Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study.

BACKGROUND: Adhesions after abdominal and pelvic surgery are important complications, although their basic epidemiology is unclear. We investigated the frequency of such complications in the general population to provide a basis for the targeting and assessment of new adhesion-prevention measures. METHODS: We used validated data from the Scottish National Health Service medical record linkage database to identify patients undergoing open abdominal or pelvic surgery in 1986, who had no record of such surgery in the preceding 5 years. Patients were followed up for 10 years and subsequent readmissions were reviewed and outcomes classified by the degree of adhesion. We also assessed the rate of adhesion-related admissions in 1994 for the population of 5 million people. FINDINGS: 1209 (5.7%) of all readmissions (21,347) were classified as being directly related to adhesions, with 1169 (3.8%) managed operatively. Overall, 34.6% of the 29,790 patients who underwent open abdominal or pelvic surgery in 1986 were readmitted a mean of 2.1 times over 10 years for a disorder directly or possibly related to adhesions, or for abdominal or pelvic surgery that could be potentially complicated by adhesions. 22.1% of all outcome readmissions occurred in the first year after initial surgery, but readmissions continued steadily throughout the 10-year period. In 1994, 4199 admissions were directly related to adhesions. INTERPRETATION: Postoperative adhesions have important consequences to patients, surgeons, and the health system. Surgical procedures with a high risk of adhesion-related complications need to be identified and adhesion prevention carefully assessed.

Abdomen↗
PubMed1999

Knowledge, attitudes and behaviour towards HIV infection among family planning clinic attendees: changes between 1991 and 1997.

AIM: To detect changes in knowledge, attitudes and behaviour towards HIV infection amongst Family Planning Clinic attendees in Christchurch, New Zealand, between 1991 and 1997. METHODS: A voluntary, anonymous, self-administered questionnaire was applied to consecutive subjects attending the Montreal Centre of the Family Planning Association in Christchurch, in 1991 and repeated in 1997. Results were compared to assess changes in demographic features, knowledge, attitudes and behaviour pertaining to HIV infection between these times. RESULTS: A 99% response rate was obtained in 1991 and 98% in 1997. Two hundred people in 1991 and 353 people in 1997 responded. These predominantly female heterosexual groups were demographically similar. Levels of knowledge pertaining to HIV infection were high and did not change significantly between 1991 and 1997, except for a rise in the proportion who felt donating blood was a high risk behaviour from 12.0% to 25.7% (p<0.001). HIV testing and discussion about HIV testing amongst couples was more common in 1997. However, the use of recreational intravenous drugs rose from 5.0% to 10.6% (p=0.025), condom use with every new partner fell from 65.1% to 42.1% (p=0.001) and the perceived risk of acquiring HIV in New Zealand and several Western Hemisphere countries fell, with 40.0% perceiving the South Island as a high-risk place in 1991 to 24.1% in 1997(p<0.001). This was paralleled by an apparent rise in known HIV testing. CONCLUSIONS: This predominantly heterosexual population appears to have maintained good levels of knowledge about HIV infection. However, this does not seem to be being translated into safer behaviour. This study detects alarming changes in behaviour in the face of adequate knowledge levels and increased testing for HIV which may provide pathways for entry of HIV into, and transmission within, the heterosexual population of New Zealand. Several aims of the New Zealand Strategy on HIV/AIDS 1990 need to be revisited in light of the evidence and resources directed appropriately.

Adolescent↗
PubMed1999

International economic analysis of primary prevention of cardiovascular disease with pravastatin in WOSCOPS. West of Scotland Coronary Prevention Study.

AIMS: The results of the West of Scotland Coronary Prevention Study (WOSCOPS) demonstrated the clinical benefit of using pravastatin for the primary prevention of cardiovascular disease in hypercholesterolaemic men. To inform decision makers, who must also consider costs, this study assesses the economic efficiency of such an intervention in a broad range of countries. METHODS AND RESULTS: A generalized model of cardiovascular disease prevention was used to estimate the cost-effectiveness of primary prevention with pravastatin compared to diet alone. This model follows a cohort of hypercholesterolaemic men over a given period quantifying the effect in terms of the avoidance of cardiovascular disease based on treatment-specific risks derived from WOSCOPS data and extensive record-linkage data on disease-specific survival. Country-specific costs are accounted for by expressing all such parameters in terms of the ratio of monthly treatment to that of managing a myocardial infarction. Over a broad range of inputs the cost-effectiveness ratios remain below $25,000 per life years gained, regardless of country. Subgroups with even better economic efficacy can be defined on the basis of higher baseline risk. CONCLUSIONS: In contrast to some previous reports, this analysis based on trial data demonstrates that pravastatin provides not only an effective means of primary cardiovascular disease prevention, but also an efficient one.

Aged↗
PubMed1998

An economic evaluation of vaccination against hepatitis A for frequent travellers.

This paper compares the cost of using inactive Hepatitis A vaccine relative to immunoglobulin as a means of protecting frequent travellers against Hepatitis A. The number of trips to 'at risk' areas is modelled as a Poisson process and results are reported in terms of the discounted gross cost per protected trip over a 10-year period. We find that the expected cost of immunization is lower with immunoglobulin for travellers visiting 'at risk' areas less than five times in 10 years, and lower with Hepatitis A vaccine for those visiting 'at risk' areas more than five times in 10 years.

Cost-Benefit Analysis↗
PubMed1998

The direct costs to the NHS of discontinuing and switching prescriptions for hypertension.

There is much evidence to suggest that the treatment of hypertension reduces the risk of cardiovascular diseases and that it is cost-effective in most patients. However, the effectiveness of treatment relies on compliance and maintenance of treatment. Each pharmacological agent differs in terms of side effects. The existence of side effects can result in poor compliance and switching between treatments. A number of studies have reported high discontinuation rates for anti-hypertensive therapies. This potentially imposes costs on the health service. The aim of this study is to use the MEDIPLUS data set to consider the cost arising from switching and discontinuation of therapy. The analysis will assess the resource costs in terms of extra GP visits and hospitalisations arising from individuals switching and discontinuing treatments. The total costs of hypertension were estimated to be around 76.5 m pound sterling per annum, of which 26.9 m pound sterling can be attributed to patients who switch or discontinue therapy.

Adult↗
PubMed1998

Cost-effectiveness of anticoagulation in nonrheumatic atrial fibrillation in the primary prevention of ischemic stroke.

BACKGROUND AND PURPOSE: A number of clinical trials have shown the value of anticoagulating patients with nonrheumatic atrial fibrillation to prevent ischemic stroke. The purpose of this study was to assess the cost-effectiveness of anticoagulation in nonrheumatic atrial fibrillation with particular reference to the very elderly (aged >75 years) who have a higher incidence of bleeding events while undergoing anticoagulation. METHODS: We calculated the incremental costs per life-year gained for 4 base cases using efficacy data from the Boston Area Anticoagulation Trial for Atrial Fibrillation, the meta-analysis of the 5 nonrheumatic atrial fibrillation trials, cost data from a district general hospital, and review of the literature. RESULTS: The cost per life-year gained free from stroke over 10 years ranged from -pound sterling 400.45 (ie, a resource saving achieved for each life-year gained free from stroke) to pound sterling 13,221.29. The results were most sensitive to alteration in the frequency of anticoagulation monitoring. CONCLUSIONS: For medical and economic reasons, anticoagulation treatment in the prevention of ischemic stroke is justified. Although older patients are more at risk of adverse events, anticoagulation is more cost-effective in this group.

Aged↗
PubMed1997

The West of Scotland coronary prevention study: economic benefit analysis of primary prevention with pravastatin.

OBJECTIVE: To estimate the economic efficiency of using pravastatin to prevent the transition from health to cardiovascular disease in men with hypercholesterolaemia. DESIGN: Economic benefit analysis based on data from the West of Scotland coronary prevention study. Treatment specific hazards of developing cardiovascular disease according to various definitions were estimated. Scottish record linkage data provided disease specific survival. Cost estimates were based on extracontractual tariffs and event specific average lengths of stay calculated from the West of Scotland coronary prevention study. SUBJECTS: Men with hypercholesterolaemia similar to the subjects in the West of Scotland coronary prevention study. MAIN OUTCOME: Cost consequences, the number of transitions from health to cardiovascular disease prevented, the number needed to start treatment, and cost per life year gained. RESULTS: If 10,000 of these men started taking pravastatin, 318 of them would not make the transition from health to cardiovascular disease (number needed to treat, 31.4), at a net discounted cost of 20m Pounds over 5 years. These benefits imply an undiscounted gain of 2,460 years of life, and thus 8121 Pounds per life year gained, or 20,375 Pounds per life year gained if benefits are discounted. Restriction to the 40% of men at highest risk reduces the number needed to treat to 22.5 (5601 Pounds per life year gained (undiscounted) and 13,995 Pounds per life year gained (discounted)). CONCLUSIONS: In subjects without evidence of prior myocardial infarction but who have hypercholesterolaemia, the use of pravastatin yields substantial health benefits at a cost that is not prohibitive overall and can be quite efficient in selected high risk subgroups.

Anticholesteremic Agents↗