Biomedical subjects
D Whynes
Publications and source records attributed to D Whynes.
The role of community pharmacists in prescribing medication for the treatment of head lice.
BACKGROUND: The aim of the study was to discover whether the use of community pharmacy, rather than general practice, as the first port of call for suspected head lice infestation would represent an acceptable, effective and cost-reducing means of management in the community. METHODS: A before-and-after study was carried out of a new system of care delivery. Between September and November 1997, pharmacists in Nottingham City West recorded details of all patients attending with prescriptions for head lice treatment or those purchasing over-the-counter medication. The new system of care delivery began in January 1998, during which, pharmacists were providing advice and treatment for head lice, in the absence of a referral from general practice. Changes in prescribing behaviour were assessed from Prescribing Analysis and Cost (PACT) data. Acceptability and subjective assessment of the scheme (patients and professionals) was gauged from questionnaires. RESULTS: Referral patterns were altered drastically (away from general practice and towards self-referral) by the project, and the changes were apparent within the first month. This trend continued throughout and beyond the formal evaluation period. Cost analysis suggests that the community pharmacy scheme generates resource savings, largely driven by the lower cost of a pharmacy consultation, as opposed to a GP consultation. Questionnaire evidence suggests that both patients and health care professionals viewed the new arrangement as at least as acceptable as the old. CONCLUSION: With respect to the original objective, the new delivery system appears to provide no evidence of ineffectiveness; evidence of acceptability on the part of the majority of patients and professionals; and evidence of improved cost-effectiveness.
Mass population screening for colorectal cancer: factors influencing subjects' choice of screening test.
OBJECTIVES: To identify socio-demographic, economic, medical and attitudinal factors that explain subjects' choice of test for screening for colorectal cancer (biennial faecal occult blood test versus once-only flexible sigmoidoscopy). METHODS: Data obtained from a questionnaire, administered by general practitioners and returned by approximately 2700 asymptomatic subjects. Thereafter, logistic regression modelling to explain willingness to participate in screening, whether or not a test preference is expressed, and the nature of the preference. RESULTS: An interest in undertaking screening is more probable if the subject is white, older, married and possesses a high health motivation. An intention to participate is more probable if the subjects are particularly worried about the disease, feel themselves to be particularly susceptible to it, and have already had experience of screening for colorectal and (if female) other cancers. Persons in receipt of a household income below 10,000 Pounds are less likely to express an interest in screening. Women are more likely to express a test preference and this preference is more likely to be for the faecal occult blood test. Subjects' worries and perception of risk are associated with reported experiences of cancer, stomach problems and depression. A positive attitude towards screening is positively associated with frequency of dental visits. CONCLUSIONS: Socio-demographic, economic and other factors evidently influence subjects' preferences for particular screening tests and, by implication, the likelihood of compliance with any future screening offer. The models support the view that participation in colorectal cancer screening has as much to do with a positive attitude towards health and health promotion generally as with any specific concern about the disease.
A prescription for improvement? An observational study to identify how general practices vary in their growth in prescribing costs.
OBJECTIVE: To identify how some general practices have low growth in prescribing costs relative to other practices. DESIGN: Observational study. SETTING: Trent region of England. PARTICIPANTS: 162 general practices: 54 with low growth in prescribing costs, 54 with average increases in costs, and 54 with large increases in costs. MAIN OUTCOME MEASURES: Changes in prescribing costs in therapeutic categories in which it has been suggested that savings can be made. RESULTS: There were significant differences between the three groups of practices in terms of their changes in prescribing costs for almost all the variables studied. For the group of practices with lowest growth in costs the most important factors were reducing numbers of prescription items and costs per item; relatively low growth in the costs of "new and expensive" drugs; increasing generic prescribing; and reducing costs for modified release products. This group of practices did not increase costs as much as the others for lipid lowering drugs (P=0.012) and hormone replacement therapy (P=0. 007). The practices with the greatest increases in costs had particularly large increases for proton pump inhibitors, selective serotonin reuptake inhibitors, and modified release products. Compared with the other groups these practices had larger increases in costs for "expensive hospital initiated drugs" (P=0.009). CONCLUSION: General practices vary in their growth in prescribing costs in many ways, with growth in costs for "new and expensive" drugs being particularly important.
An economic evaluation of occupational health.
There is an increasing need to evaluate the costs and benefits of an occupational health service (OHS). However, measuring benefits from an OHS is inherently difficult. Instead, an economic model can be constructed to present the minimum threshold benefits required for OHSs to be cost-effective, given what is known about costs. This model assumes that the benefits of an OHS are to maximize health and morale of employees; maximize performance and increase productivity; minimize medico-legal costs; enhance workplace safety; and reduce sickness absence. A certain distribution across these benefits can be assumed for each OHS. The overall required value of all benefits brought about by use of an OHS is in the range 158-199 Pounds per year. The plausibility of results can be assessed using known data and judgement. Despite many uncertainties it is likely that the minimum benefit thresholds will be achieved overall.
Cost-effectiveness and cost-benefit in the prevention of mother-to-child transmission of HIV in developing countries. Ghent International Working Group on Mother-to-Child Transmission of HIV.
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The use of the ASTRO-PU and the ASTRO(97)-PU in the setting of prescribing budgets in English general practice.
OBJECTIVES: To examine the variation in prescribing costs explained by the Age, Sex and Temporary Resident Originated Prescribing Unit (ASTRO-PU) and its replacement, the ASTRO (97)-PU, in order to determine the appropriateness of their use in the setting of prescribing budgets in English general practice. METHODS: Linear regression analysis was used to analyse routinely collected patient and prescribing data from one English health authority (Lincolnshire Health) for the fiscal year 1995. RESULTS: The goodness-of-fit of the regression models constructed varied according to whether practices had dispensing status (i.e. rural practices that have permission to dispense drugs to their own patients as a means of compensating for the lack of pharmacies in such areas), with the ASTRO-PU and ASTROP(97)-PU explaining a higher proportion of the variation in prescribing costs amongst practices with such status. CONCLUSIONS: This paper draws two main conclusions. First, the weights embodied in the ASTRO-PU and the ASTRO(97)-PU may have been biased by the number of dispensing practices sampled during their construction. Second, the denominators may be more applicable to dispensing practices, implying that primary care groups may need to follow the principle of 'local flexibility' during the budget-setting process.
Prescribing. Saving graces.
If fundholding is to be dismantled, consideration must be given to fundholders' prescribing budgets. One possibility would be budgeting by consent--involving GPs in setting budgets. More research is needed on prescribing budgets before they are abandoned.
Predicting activity and workload in general practice from the demographic structure of the practice population.
OBJECTIVES: The managerial requirements of budget-setting and performance monitoring in general practice (primary care) in the UK require an understanding of the causal relationship between practice activities and the characteristics of both the practice and its patients. This study sought to model the determinants of three major components of general practice activities (consultations, prescribing costs and referrals to secondary care), paying particular attention to the influence of the demographic structure of the patient list. METHODS: Stepwise regression analysis was carried out on data for 98 practices in the county of Lincolnshire using 12 independent variables pertaining to patient and practice characteristics plus 14 statistical measures derived from the demographic structure of the patients registered with the practice. RESULTS: Robust statistical models were estimated for the three dependent variables, of which list size emerged as the most significant independent variable. In addition, six other independent variables, including the patients' unemployment rate, fundholding status and single-handed status, were statistically significant in one or more of the equations. Variables based on the demographic structure of the practice population also appeared in each model. The Jarman score and degree of urbanization did not achieve statistical significance. CONCLUSIONS: Activity and workload in general practice can be predicted from routine data. Such models are of particular value for planning and financial management when demographic change in practice populations is anticipated.
Cost comparison of domiciliary and hospital-based stroke rehabilitation. DOMINO Study Group.
The DOMINO study (DOMiciliary rehabilitation In NOttingham) was a randomized controlled trial comparing domiciliary and hospital-based rehabilitation for stroke patients after discharge from hospital, stratified according to the ward at hospital discharge. The outcomes of these patients have been reported previously. In this paper, we present estimates of health service costs of care. No difference in outcome had been found between the overall services, but we have found the hospital-based costs to be 27% cheaper. However, different cost-effectiveness patterns are observable when the strata are analysed. Patients from geriatric wards had been shown to be 2.4 times less likely to die or become institutionalized by 6 months if allocated to a day hospital service, although the cost of this service was 25% more than that of the domiciliary service. Patients from the Stroke Unit who had received domiciliary rehabilitation had been shown to have greater household and leisure abilities at 6 months than those treated in outpatient departments, but the domiciliary service was found to cost 2.6 times more. Patients from general medical wards had similar outcomes whether treated at home or in outpatient departments, but the cost of the latter service was 56% of the former. Some patients may be best cared for in day hospitals and others may do better if treated at home, but for these groups the clinical advantages are achieved at an expense greater than that incurred by the alternative services. Other patients may do as well if treated in outpatient departments as at home, but the former approach is cheaper. A range of services is required for stroke patients leaving hospital.
When the future is in futures.
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Class A drug users: prevalence and characteristics in greater Nottingham.
This paper reports on the prevalence of known Class A drug use in Greater Nottingham, a large urbanized area with a population of 472,285 in 1981. Use of a multi-agency enumeration technique identified only 170 users during 1985-86, giving an annual prevalence of 0.45 per 1000 of the adult population. The rates for opioid use and injected amphetamine use were 0.27 and 0.14 per 1000. Geographical analysis of the intra-urban residential distributions of the drug users identified statistically significant variations with the greatest concentrations occurring in the inner city residential areas, in neighbourhoods fringing major suburban shopping centres, and several council estates. Ecological analysis established statistically significant links between drug use and multiple deprivation, adult unemployment and crime.