Improving the cost-effectiveness of colorectal cancer screening.
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Colorectal Neoplasms↗
Biomedical subjects
D K Whynes
Publications and source records attributed to D K Whynes.
Measuring concentration in primary care.
There is evidence that patient choice and the quality of service delivery in primary care can be influenced by the organisation and structure of provision at the local level. However, the formal measurement of structure in primary care has yet to be undertaken. Using data for Coventry, standard concentration measures are estimated, which show that concentration varies considerably across the city and tends to be higher in areas of lower deprivation. Assuming that patient choice is an important consideration in health care planning, concentration measurement may provide a useful tool for health authorities in making decisions about GP numbers, practice mergers and re-location.
Catchment Area, Health↗
Prevention of mother-to-child transmission of HIV in developing countries: recommendations for practice. The Ghent International Working Group on Mother-To-Child Transmission of HIV.
OBJECTIVES: Different approaches to prevent mother-to-child transmission of HIV are being evaluated in developing countries. The first trials using a short regimen of zidovudine have been successful in Thailand, Côte d'Ivoire and Burkina Faso. International and local strategies are now being considered. The Ghent International Working Group on Mother-to-Child Transmission of HIV developed public health policy options to integrate these interventions into basic and maternal and child health (MCH) services. METHODS: The following tasks were undertaken: a critical review of randomized trials; an international pooled analysis of late postnatal transmission of HIV through breastfeeding; a review of the cost-effectiveness and cost-benefit of antiretroviral prophylaxis; a feasibility assessment of preventive strategies, including a postal survey on HIV voluntary counselling and testing (VCT) of pregnant women; the identification of requirements and research priorities for prenatal, obstetric and paediatric care. These projects provided the background for a three-day workshop in Ghent, Belgium, in November 1997. Conclusions were further refined, based on 1998 research findings. RESULTS: A summary of relevant evidence and ten public health recommendations are reported. VCT for pregnant women, a short regimen of zidovudine together with alternatives to breastfeeding currently represent the best option to reduce vertical transmission in most developing countries. The primary goal of the integrated package supporting these interventions is to alleviate overall maternal and infant morbidity and mortality. CONCLUSION: Prevention of mother-to-child transmission of HIV should now be considered for integration into basic health and MCH services of selected countries, with the involvement of governments and donor agencies.
Anti-HIV Agents↗
Cost-effectiveness of faecal occult blood screening for colorectal cancer: results of the Nottingham trial.
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Colorectal Neoplasms↗
The hospital costs of treating lung cancer in the United Kingdom.
A detailed patient-by-patient costing analysis, based on case records for 253 patients diagnosed in 1993, reveals that the mean 4-year diagnosis and management costs amounted to Pound Sterling 6150 and Pound Sterling 5668 for non-small cell and small cell lung cancer respectively. These costs are lower than those identified in Canadian studies, the difference being explained by the use of a simulated costing methodology in these studies, lower unit costs and less aggressive interventions.
Hospital Costs↗
Estimating time and travel costs incurred in clinic based screening: flexible sigmoidoscopy screening for colorectal cancer.
OBJECTIVES: To identify the characteristics of mode of travel to screening clinics; to estimate the time and travel costs incurred in attending; to investigate whether such costs are likely to bias screening compliance. SETTING: Twelve centres in the trial of flexible sigmoidoscopy screening for colorectal cancer, drawn from across Great Britain. METHOD: Analysis of 3525 questionnaires completed by screening subjects while attending clinics. Information supplied included sociodemographic characteristics, modes of travel, expenses, activities foregone owing to attendance, and details of companions. RESULTS: More than 80% of subjects arrived at the clinics by car, and about two thirds were accompanied. On average, the clinic visit involved a 14.4 mile (22.8 km) round trip, requiring 130 minutes. Mean travel costs amounted to 6.10 Pounds per subject. The mean gross direct non-medical and indirect cost per subject amounted to 16.90 Pounds, and the mean overall gross cost per attendance was 22.40 Pounds. Compared with the Great Britain population as a whole, non-manual classes were more strongly represented, and the self employed less strongly represented, among the attendees. CONCLUSIONS: In relation to direct medical costs, the time and travel costs of clinic based screening can be substantial, may influence the overall cost effectiveness of a screening programme, and may deter potential subjects from attending.
Aged↗
Controlled trial of pharmacist intervention in general practice: the effect on prescribing costs.
BACKGROUND: It has been suggested that the employment of pharmacists in general practice might moderate the growth in prescribing costs. However, empirical evidence for this proposition has been lacking. We report the results of a controlled trial of pharmacist intervention in United Kingdom general practice. AIM: To determine whether intervention practices made savings relative to controls. METHOD: An evaluation of an initiative set up by Doncaster Health Authority. Eight practices agreed to take part and received intensive input from five pharmacists for one year (September 1996 to August 1997) at a cost of 163,000 Pounds. Changes in prescribing patterns were investigated by comparing these practices with eight individually matched controls for both the year of the intervention and the previous year. Prescribing data (PACTLINE) were used to assess these changes. The measures used to take account of differences in the populations of the practices included the ASTRO-PU for overall prescribing and the STAR-PU for prescribing in specific therapeutic areas. Differences between intervention and control practices were subjected to Wilcoxon matched-pairs, signed-ranks tests. RESULTS: The median (minimum to maximum) rise in prescribing costs per ASTRO-PU was 0.85 Pound (-1.95 Pounds to 2.05 Pounds) in the intervention practices compared with 2.55 Pounds (1.74 Pounds to 4.65 Pounds) in controls (P = 0.025). Had the cost growth of the intervention group been as high as that of the controls, their total prescribing expenditure would have been around 347,000 Pounds higher. CONCLUSION: This study suggests that the use of pharmacists did control prescribing expenditure sufficiently to offset their employment costs.
Community Pharmacy Services↗
Faecal occult blood screening for colorectal cancer: is it cost-effective?
Recently published evidence from two large-scale clinical trials conducted in England and in Denmark suggests that faecal occult blood screening for colorectal cancer significantly reduces mortality. However, before screening can be advocated as part of national health policy, its cost-effectiveness must be demonstrated. The English screening trial has been the subject of a detailed economic evaluation over the past 10 years In this paper, cost-effectiveness estimates of screening are presented, based on cost and outcome data combined in a mathematical model developed from the trial's clinical findings The estimates of cost per quality-adjusted life-year gained from colorectal cancer screening show the procedure to be of similar cost-effectiveness to breast cancer screening in the short term. Over the longer term, however, the estimates for colorectal cancer screening appear superior.
Aged↗
General practitioners' referral thresholds and choices of referral destination: an experimental study.
General practitioners (GPs) exert a major impact on NHS resource use, both as providers of primary care and as referrers to secondary care. Referral rates are subject to wide variations, leading to the conjecture that certain GPs may have different 'referral thresholds' from those of others. In this paper, the authors describe an experiment designed both to test the referral threshold hypothesis and to illuminate the GP's decision process with respect to choice over referral destination. Nottinghamshire GPs were provided with hypothetical case histories and a list of possible referral destinations, specifying a range of consultants, their specialist interests, plus the expected waiting times and costs for both out-patient investigation and in-patient treatment. For each case, respondents were requested to indicate whether or not they would refer the patient, and to whom. Respondents were also asked to indicate the extent to which their choices of consultants generally were governed by the specialist interest, the waiting time and the cost information. The responses of the sample support the referral threshold conjecture, with specialist interests and waiting time appearing to be far more important than cost in influencing choice of referral destination. The possibilities of influencing GPs' referral behaviour are discussed, in the light of recent initiatives with respect to prescribing.
Adult↗
Income-based incentives in UK general practice.
Since 1990, income-based economic incentives have ostensibly become more important in the remuneration structure of UK general practitioners. For incentives to fulfil their role, however, GPs must possess discretion over income-generating activity and be assumed to be income maximisers. Evidence from one English health authority suggests that a very high proportion of GP income continues to be determined by patient characteristics and the scope for a discretionary response to income incentives is correspondingly small. Where discretion does exist, higher levels of GP incomes do not appear to militate against further discretionary income raising, except in the case where this income and budgetary discipline are in conflict.
Analysis of Variance↗
The ethics of resource allocation: the views of general practitioners in Lincolnshire, U.K.
Concerns about the intrusion of economic and financial considerations into patient management have increased in the United Kingdom, largely as a result of the passage of the 1990 National Health Services Act. Based on an agenda set by the British Medical Association, a questionnaire was designed to reveal general practitioners' attitudes to potential ethical problems posed by rationing and resource allocation. The questionnaire was issued to each of the 105 practices in Lincolnshire and 70 replies were returned for analysis. The survey revealed that, in certain areas, there existed a wide divergence of opinion amongst physicians. Examples included the extent to which the government was to be held responsible for full health care funding, the legitimacy or otherwise of general practice budgets and the extent to which service provision should be dependent on upon personal remuneration. On the other hand, relatively high degrees of consensus appeared to exist with respect to issues such as rationing by deterrence and service dilution. Additional, qualitative, evidence suggests that practitioners perceive themselves to be under increasing pressure from patient demand and that morale in the profession is falling. The results of the present study appear consistent with those obtained in other countries. In view of recent policy initiatives with respect to public sector health care, it is likely that the debate over the ethical dimensions of resource allocation in the U.K. will become more vigorous.
Attitude of Health Personnel↗
Stage-specific treatment costs for cervical cancer in the United Kingdom.
In order to examine the relationship between stage at initial diagnosis and management costs for cervical cancer, a detailed cost audit over 5 years was conducted on a sample of patients diagnosed in 1990 in one U.K. region. The mean costs of managing pre-invasive carcinoma (386 Pounds) were found to be significantly lower than those of stage 1 invasive carcinoma (6623 Pounds) and both were lower than the costs of invasive cancer at stages 2-4 (10,910 Pounds, 10,579 Pounds and 11,035 Pounds, respectively). A comparison of management costs for cervical cancer with those of breast cancer by stage revealed both that the former are invariably higher and that the cost-by-stage profiles for the two diseases are dissimilar.
Cost-Benefit Analysis↗
The costs of treating breast cancer in the United Kingdom: implications for screening.
Total treatment costs by stage at diagnosis are estimated for a sample of breast cancer patients. At 4 years, stage 4 cancers emerge as being more expensive to treat than those at earlier stages, although this difference fails to achieve significance when expected lifetime costs are considered. The inclusion of treatment cost estimates in a screening model indicates that screening may increase expected treatment costs by a marginal amount, although the model also suggests that the cost-effectiveness ratio of breast cancer screening might be better than had originally been thought.
Adult↗
Assessing efficiency in general practice: an application of data envelopment analysis.
As with any health care process, the efficiency with which outputs are produced in general practice is of considerable importance. Using data from Lincolnshire, this study utilizes data envelopment analysis to examine the relationships between practice costs and outputs, measured not only as the number of patients treated, but also on the basis of performance indicators. The technique permits the construction of an efficiency ranking, facilitating the accurate targeting of monitoring resources.
Benchmarking↗
Symptoms before and after surgery for colorectal cancer.
Questionnaires were completed by a sample (n = 53) of patients at two points in time, prior to surgery for colorectal cancer and three months thereafter. The questionnaires comprised the Nottingham Health Profile, as a general health status measure, and a specific checklist of 30 symptoms. Of the physical symptoms, loss of appetite, rectal bleeding and urgency of bowel movement appeared to decline after treatment, whilst other potential symptoms, such as vomiting, appeared to occur only rarely, both before and after surgery. Pre-treatment symptoms of psychological distress appeared to have dissipated by three months, suggesting that they were more likely to have resulted from the anticipation of treatment rather from the disease itself. A logistic regression model suggests that the presence of certain symptoms, such as rectal bleeding and heartburn, is more likely to be associated with the presence of late- as opposed to early-stage cancer.
Colorectal Neoplasms↗
GP fundholding and the costs of prescribing: further results.
BACKGROUND: An earlier paper published in this journal suggested that fundholding practices in Lincolnshire had managed to constrain the growth in their prescribing costs more successfully than had non-fundholders, largely on the basis of restricting the number of items prescribed per patient. At that time, insufficient data were available to explore the impact of a change in status from non-fundholding to fundholding on prescribing behaviour. METHOD: Time-series prescribing data for the fourth-wave of Lincolnshire fundholders are analysed, and comparisons are made between this group, non-fundholders and the fundholders of the earlier waves. RESULTS: In their first year of fundholding, fourth-wave practices adopted the prescribing strategies employed previously by existing fundholders, namely, reductions in the number of items prescribed per patient and substantial increases in generic prescribing. The hypothesis that prospective fundholders inflate their prescribing budget before attaining fundholding status is not generally supported by the Lincolnshire data. Evidence is presented which suggests that the prescribing cost economies accruing to fundholding status may be short term. CONCLUSIONS: With the acquisition of fundholding status, the structure of incentives facing practices changes. Our results suggest that, with respect to prescribing, practices adjust rapidly to the new incentive structure.
Drug Costs↗
Interferon-beta in multiple sclerosis. Can we control its costs?
The recent licensing of interferon-beta for use in patients with multiple sclerosis has caused concern, in view of the equivocal evidence of efficacy, pressure of public expectation towards its use and the high expected cost if widespread use were to be sanctioned. Whether such alarm is justified remains a moot point. Owing to the limited range of circumstances of proven efficacy and the lack of cost-effectiveness data, it remains unclear whether sanctioned usage will proliferate to the anticipated extent. Unit costs may well fall in the future owing to competition in the pharmaceutical market. Interferon-beta is simply one example of a growing trend in actively promoted high-cost preparations over which rationing decisions will have to be reached.
Cost-Benefit Analysis↗
General practitioner fundholding and prescribing expenditure control. Evidence from a rural English health authority.
In April 1991, the fundholding and indicative prescribing schemes introduced budgets for expenditure on prescribed drugs into UK general practice. Although both schemes were designed to be equally effective at containing prescribing-cost inflation, several studies suggest that expenditure growth has been lower in fundholding practices, compared with nonfundholding practices. This study attempts to ascertain how fundholding practices control their expenditure by examining data from a rural English health authority for the financial year 1993 to 1994. The fundholding practices sampled were found to control their expenditure through: (i) reduced overprescribing; (ii) using fewer drugs that have limited clinical value; (iii) substituting similar, but less expensive, drugs; (iv) more generic prescribing; and (v) appropriate use of expensive preparations. However, whether the cost differential between fundholding and nonfundholding practices is sustained in future years will depend upon: (i) the ability of fundholding practices to generate further savings; (ii) the characteristics of the practices that enter the fundholding scheme in subsequent waves; (iii) the way in which the scheme is organised; and (iv) the level at which budgets are set.
Cost Control↗