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Biomedical subjects

E McIntosh

Publications and source records attributed to E McIntosh.

At least 19 recordsLinked to original sources
PubMed2005

Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation.

OBJECTIVES: To determine whether laparoscopic methods are more effective and cost-effective than open mesh methods of inguinal hernia repair, and then whether laparoscopic transabdominal preperitoneal (TAPP) repair is more effective and cost-effective than laparoscopic totally extraperitoneal (TEP). DATA SOURCES: Electronic databases. Conference proceedings. Manufacturers' submissions to the National Institute for Clinical Excellence (NICE) were reviewed. REVIEW METHODS: Selected studies were rigorously assessed. Dichotomous outcome data were combined using the relative risk method and continuous outcomes were combined using the Mantel-Haenszel weighted mean difference method. Time to return to usual activities was described using hazard ratios derived from individual patient data reanalysis. A review of economic evaluations undertaken by NICE in 2001 was updated and an economic evaluation was performed. The estimation of cost-effectiveness focused on the comparison of laparoscopic repair with open flat mesh. A Markov model incorporating the data from the systematic review was used to estimate cost-effectiveness for a time horizon up to 25 years. RESULTS: Thirty-seven randomised control trials (RCTs) and quasi-RCTs met the inclusion criteria on effectiveness. Fourteen studies were included in the review of economic evaluations. Laparoscopic repair was associated with a faster return to usual activities and less persisting pain and numbness. There also appeared to be fewer cases of wound/superficial infection and haematoma. However, operation times are longer and there appears to be a higher rate of serious complications in respect of visceral (especially bladder) injuries. Mesh infection is very uncommon with similar rates noted between the surgical approaches. There is no apparent difference in the rate of hernia recurrence. Laparoscopic repair was more costly to the health service than open repair, with an estimated extra cost from studies conducted in the UK of about 300-350 pounds per patient. The point estimates of cost provided by the economic model also suggest that the laparoscopic techniques are more costly (approximately 100-200 pounds more per patient after 5 years). From the review of economic evaluations, the estimates of incremental cost per additional day at usual activities were between 86 pounds and 130 pounds. Where productivity costs were included, they eliminated the cost differential between laparoscopic and open repair. Additional analysis incorporating new trial evidence suggested that TEP was associated with significantly more recurrences than open mesh but these data did not greatly influence cost-effectiveness. CONCLUSIONS: For the management of unilateral hernias, the base-case analysis and most of the sensitivity analysis suggest that open flat mesh is the least costly option but provides less quality adjusted life years (QALYs) than TEP or TAPP. TEP is likely to dominate TAPP (on average TEP is estimated to be less costly and more effective). It is likely that, for management of symptomatic bilateral hernias, laparoscopic repair would be more cost-effective as differences in operation time (a key cost driver) may be reduced and differences in convalescence time are more marked (hence QALYs will increase) for laparoscopic compared with open mesh repair. When possible repair of contralateral occult hernias is taken into account, TEP repair is most likely to be considered cost-effective at threshold values for the cost per additional QALY above 20,000 pounds. The increased adoption of laparoscopic techniques may allow patients to return to usual activities faster. This may, for some people, reduce any loss of income. For the NHS, increased use of laparoscopic repair would lead to an increased requirement for training and the risk of serious complications may be higher. Chronic pain should now be addressed prospectively using standard definitions and allowing assessment of the degree of pain. More evidence is required on the loss of utility caused by persisting pain and numbness, as well as serious complications resulting from minor surgery. Prospective population-based registries of new surgical procedures may be the best way to address this, as a complement to randomised trials assessing effectiveness. Further research relating to whether the balance of advantages and disadvantages changes when hernias are recurrent or bilateral is also required as current data are limited. Methodologically sound RCTs are needed to consider the relative merits and risks of TAPP and TEP. Further methodological research is required into the complexity of laparoscopic groin hernia repair and the improvement of performance that accompanies experience.

Cost-Benefit Analysis↗
PubMed2004

Determinants of quality of life in first-episode psychosis.

OBJECTIVE: To assess patient and/or illness characteristics associated with aspects of quality of life (QOL) in first-episode psychosis (FEP). METHOD: Patient characteristics, symptom ratings and Wisconsin QOL scale (client version) were assessed. Data were analysed with correlation coefficients and a hierarchical regression analysis. RESULTS: Patients presented with varying levels of QOL on different domains. The level of 'general satisfaction' was related to age of onset and social premorbid adjustment; 'weighted index of QOL' to social premorbid adjustment and inversely to educational premorbid adjustment; 'social relations' inversely to duration of untreated psychosis (DUP), length of prodrome and negative symptoms; 'psychological well-being' inversely to depression and educational premorbid adjustment; 'activities of daily living' to social premorbid adjustment and inversely to negative symptoms; and 'outlook on symptoms' to level of depression. CONCLUSION: Domains of self-rated QOL in FEP patients are differentially associated with malleable and non-malleable aspects of patient and illness characteristics.

Adult↗
PubMed2004

Does early imaging influence management and improve outcome in patients with low back pain? A pragmatic randomised controlled trial.

OBJECTIVES: To establish whether the early use of sophisticated imaging techniques influences the clinical management and outcome of patients with low back pain (LBP) and whether it is cost-effective. DESIGN: A pragmatic multicentre randomised controlled trial using a standard two parallel group approach incorporating an economic evaluation. For a subgroup of trial participants, a controlled 'before and after' approach was used to assess the impact of 'early imaging' on clinicians' diagnostic and therapeutic confidence. SETTING AND PARTICIPANTS: A total of 782 participants who had been referred by their general practitioner to a consultant orthopaedic specialist or neurosurgeon because of symptomatic lumbar spine disorders. The study included 14 hospitals in Scotland and one in England over a 24-month period. RESULTS: Participants in both groups reported an improvement in health status at 8 and 24 months with the 'early imaging' group having statistically significantly better outcome. Other than the proportion of participants receiving imaging (90% versus 30%), there were few differences between the groups in the management received throughout the 24-month follow-up. The total number of outpatient consultations in the two groups was similar although more people in the 'early imaging' group had return outpatient appointments during the 8-month follow-up. Clinicians' diagnostic confidence, between trial entry and follow-up, increased significantly for both groups with a greater increase in the 'early imaging' group. The cost of imaging was the main determinant of the difference in total costs between the groups and it was estimated that 'early imaging' could provide an additional 0.07 quality-adjusted life-years (QALYs), at an additional average cost of 61 British pounds over the 24-month follow-up. Using non-imputed costs and QALYs but adjusted for baseline differences in EQ-5D score, the mean incremental cost per QALY of 'early imaging' was 870 British pounds. The results were sensitive to the costs of imaging and the confidence intervals surrounding estimates of average costs and QALYs. CONCLUSIONS: The early use of sophisticated imaging does not appear to affect management overall but does result in a slight improvement in clinical outcome at an estimated cost of 870 British pounds per QALY. Imaging was associated with an increase in clinicians' diagnostic confidence, particularly for non-specialists. Further research is required to determine if more rapid referral to sophisticated imaging and secondary care is important in the acute episode and whether the use of imaging would be more beneficial for particular categories of LBP.

Adult↗
PubMed2003

Cluster randomized trial of a guideline-based open access urological investigation service.

BACKGROUND: Out-patient services are trying to achieve effective and efficient health care in overcrowded, busy clinic settings. "One stop" and "open access" clinics have been advocated as a way of improving out-patient services. OBJECTIVES: Our aim was to evaluate the effectiveness and efficiency of a guideline-based open access urological investigation service. METHODS: General practices were randomized to receive either referral guidelines and access to the investigation service for lower urinary tract symptoms (LUTS) or referral guidelines and access to the investigation service for microscopic haematuria (MH). The study population comprised 66 general practices in the Grampian region of Scotland referring 959 patients. The outcome measures were compliance with guidelines (number of recommended investigations completed), number of general practice consultations, the number and case mix of referrals, waiting time to initial hospital appointment, and the number of patients with a management decision reached at initial appointment and discharged by 12 months after referral. RESULTS: GPs' compliance with referral guidelines increased (difference in means 0.5; 95% confidence interval 0.2-0.8, P < 0.001). Approximately 50% of eligible patients were referred through the new system. The number and case mix of referrals were similar. The intervention reduced the waiting time from referral to initial out-patient appointment (ratio of means 0.7; 0.5-0.9, patients with LUTS only) and increased the number of patients who had a management decision reached at initial appointment (odds ratio 5.8; 2.9-11.5, P < 0.00001, both conditions). Patients were more likely to be discharged within 12 months (odds ratio 1.7; 0.9-3.3, P = 0.11). There were no significant changes detected in patient outcomes. Overall the new service was probably cost saving to the NHS. CONCLUSIONS: The guideline-based open access investigation service streamlined the process of out-patient referral, resulting in a more efficient service with reduced out-patient waiting times, fewer out-patient and investigation appointments and release of specialist and clinic time.

Ambulatory Care Facilities↗
PubMed2001

Impact of phase-specific treatment of first episode of psychosis on Wisconsin Quality of Life Index (client version).

OBJECTIVE: The objective of this study was to assess the impact of a phase-specific community-focused treatment program on different dimensions of self-reported quality of life in a representative sample of first episode psychosis patients. METHOD: Data were collected on patients presenting with a first episode of psychosis on the Wisconsin Quality of Life Index (client version), positive and negative symptoms, and demographic and clinical variables at baseline following clinical stabilization and at 1 year. RESULTS: Complete data on a representative sample of 41 patients showed a significant improvement in most dimensions of the WQOL at 1 year; these changes were generally independent of changes in symptoms and there were no significant differences in the magnitude of improvement in QOL between those with DUP < or >6 months. CONCLUSION: Patients with a first episode of predominantly schizophrenia spectrum psychosis show a highly significant improvement in subjectively assessed quality of life following a year of phase-specific comprehensive treatment.

Adult↗
PubMed2001

Glucose transport regulation by p210 Bcr-Abl in a chronic myeloid leukaemia model.

The regulation of nutrient transport by both cytokines and oncogenes has been linked to haemopoietic cell survival. In this study, we found that activation of Bcr--Abl protein tyrosine kinase was associated with the stimulation of glucose transport in the multipotent haemopoietic cell line FDCP-mix, a cell model for chronic-phase chronic myeloid leukaemia (CML). Bcr--Abl upregulation of glucose transport was mediated by phosphatidylinositol-3-kinase. The observation that Bcr--Abl can regulate glucose transport in a CML cell model raises the possibility that glucose transport regulation may have a role to play in the aberrant survival of stem cells in the chronic phase of CML.

Biological Transport↗
PubMed2000

The relationship of symptoms and level of functioning in schizophrenia to general wellbeing and the Quality of Life Scale.

OBJECTIVE: Reports suggesting that quality of life in schizophrenia is more highly related to negative rather than positive symptoms are largely based on use of the Quality of Life Scale which was devised to assess deficit symptoms and does not include an assessment of subjective general wellbeing. In the current paper we examined symptoms, level of community functioning as well as living circumstances as correlates of Quality of Life Scale scores and scores on the General Well-Being Scale. METHOD: One hundred and twenty-eight patients completed the General Well-Being Scale and were rated on the Quality of Life Scale as well as scales assessing positive and negative symptoms. RESULTS: While negative symptoms, level of functioning and positive symptoms all were related to the scores on the Quality of Life Scale, General Well-Being Scale scores were primarily related to positive symptoms, particularly reality distortion. CONCLUSION: The results highlight the importance of recognizing the complex nature of the concept of quality of life. They demonstrate that varying indices of quality of life are likely to have different predictors.

Adolescent↗
PubMed2000

Nurse-sensitive outcomes of advanced practice.

Advanced practice nurses (APNs) in the USA are registered nurses who hold masters or doctoral degrees in a specialized area of nursing. They provide advanced clinical care to clients, manage health care systems and influence health care decision-making through expert clinical reasoning and research and theory-based action. APN impact on health care outcomes is supported by studies using physician-focused indicators, although a few studies have identified several that are sensitive to or reflective of advanced practice nursing. A modified Delphi survey was conducted during May 1997-December 1998 to determine the outcome indicators APNs recommend for use in measuring their effect on care delivery outcomes. A convenience sample of 66 APNs attending a statewide outcomes conference identified 27 potential outcome indicators. These indicators were included in a mailed survey sent to APNs working in Tennessee. Respondents were asked to rate each indicator for validity, sensitivity, feasibility, utility and cost. In the second round of the survey, they were asked whether or not they agreed with the rank ordering of indicators, which was determined by the means calculated from responses in the first round. The 10 highest ranked indicators were satisfaction with care delivery, symptom resolution/reduction, perception of being well cared for, compliance/adherence with treatment plan, knowledge of patients and families, trust of care provider, collaboration among care providers, frequency and type of procedures ordered and quality of life. APNs identified both direct and indirect measures of effect on care delivery outcomes. Some of these are currently used as indicators of advanced practice, but many are not. Additional research is needed to determine whether the indicators proposed are valid and sensitive to advanced practice care by nurses.

Adult↗
PubMed2000

Trade-offs between location and waiting times in the provision of health care: the case of elective surgery on the Isle of Wight.

BACKGROUND: Recent UK government documents have stated that, within the National Health Service, consumers should be more involved in decision-making. This study considered the technique of discrete choice conjoint analysis (DCCA) for eliciting community views regarding the importance of reducing waiting times. More specifically, the study aimed to establish whether residents living on the Isle of Wight are prepared to travel to the mainland for elective surgery where waiting times are shorter but travel costs may be greater, and, further, if residents are willing to travel, what reduction in waiting time and increase in travel costs would be acceptable. METHODS: A DCCA questionnaire was sent to a random sample of 1,000 individuals living on the Isle of Wight. RESULTS: Seventy-eight per cent of respondents were willing to travel to the mainland for elective surgery. Of these, 48 per cent always chose the mainland and 30 per cent traded between island and mainland, depending on the levels of waiting time and travel costs. Whereas 'traders' preferred the Isle of Wight, they would forgo their preferred location if waiting times were reduced by at least 3.9 months, and they were willing to pay over 12 for a 1 month reduction in waiting time. Different combinations of waiting time reductions and travel cost increases that were acceptable to traders were estimated. CONCLUSIONS: Carrying out elective surgery on the mainland offers the potential to reduce waiting lists for island residents. The majority of respondents would be willing to travel to the mainland. However, one-fifth of respondents were not willing to travel to the mainland for elective surgery. The preferences of this group are important in policy decisions. More generally, the paper demonstrates the potential application of DCCA to public health issues.

Adolescent↗
PubMed1999

Symptoms and cognition as predictors of community functioning: a prospective analysis.

OBJECTIVE: It has been suggested that level of cognitive functioning as assessed by formal neurocognitive tests may be as important as, or even more important than, symptoms in predicting level of community functioning for patients with schizophrenia. The results of past prospective studies, when carefully examined, do not consistently support this hypothesis. In the current study, the authors used symptom and neurocognitive data to predict subsequent level of functioning in the community. METHOD: Neurocognitive and symptom data collected as part of an earlier study were used to predict the community functioning of 50 patients with a diagnosis of schizophrenia. Using the Life Skills Profile, staff of a community mental health program assessed community functioning while blind to the earlier symptom ratings and neurocognitive performance. RESULTS: Symptoms were more predictive of community functioning than were neurocognitive measures. Disorganization symptoms were generally more predictive of community functioning than was either psychomotor poverty or reality distortion. CONCLUSIONS: The results of this study and of previous longitudinal studies suggest the importance of using symptom levels after optimal treatment, rather than symptoms during acute episodes, as predictors of community functioning. They also indicate the need to evaluate the effects of treatment on disorganization as a separable dimension of symptoms.

Adult↗
PubMed1999

Recent advances in the methods of cost-benefit analysis in healthcare. Matching the art to the science.

This paper outlines recent advances in the methods of cost-benefit analysis (CBA). Economic evaluations in healthcare can be criticised for, amongst other things, the inappropriate use of incremental cost-effectiveness ratios and the reporting of benefits in terms of cost savings, such as treatment costs averted. Many such economic evaluations are, according to the 'scientific' definition, CBAs. The 'balance-sheet' (or opportunity cost) approach is a form of CBA which can be used to identify who bears the costs and who reaps the benefits from any change. Whilst the next stage in a CBA, as defined in health economics, would require that all costs and benefits be valued in monetary terms, the balance-sheet approach, however, advocates that available monetary values can be augmented by other measures of cost and benefit. As such, this approach, which has a theoretical basis, is proposed as a practical prescription for CBA and highlights the notion that unquantified benefits are important and can be included within CBAs even when monetarisation is not possible. Recent methodological developments in monetary valuation for use in CBA are the development of the technique of willingness to pay, the use of conjoint analysis (CA) to elicit willingness-to-pay (WTP) values and advances in the debate on the inclusion of production gains in CBAs. Whilst acknowledging that there have been developments in each of these areas, it is claimed there has also been progress in using CBA as a framework for evaluation, as reflected by the balance-sheet approach. The paper concludes by stating that almost all types of economic evaluation have an element of the 'cost-benefit' approach in them. The important issue is to focus on the policy question to be addressed and to outline the relevant costs and benefits in a manner which assists the evaluation of welfare changes resulting from changes in healthcare delivery. The focus should not be on moulding a question to fit a hybrid definition of an analytical technique.

Cost-Benefit Analysis↗
PubMed1999

Hospice in the nursing home--a valuable collaboration.

Long-term care facilities have one of the most difficult tasks in health care: to maximize the health of frail elderly people. However, our society's resistance to the natural process of dying commands the assistance of hospice services in helping patients and their families cope with illness and death. The presence of such hospice services in long-term facilities is relatively recent, and the two teams are still negotiating an optimal collaboration.

Adult↗
PubMed1998

Methodological issues in the application of conjoint analysis in health care.

This paper adds to an increasing literature on methodological questions addressed in the application of conjoint analysis (CA) in health care. Three issues are addressed: ordering effects; internal validity; and internal consistency. The results of an application of CA in a primary care setting provide no evidence that the ordering of scenarios was important. Evidence was found of both internal validity and internal consistency. In addition, individual preferences were found to be determined by experiences, which raise potentially important questions regarding the elicitation and use of such preferences in economic evaluation.

Appointments and Schedules↗
PubMed1998

An integrated medical and psychosocial treatment program for psychotic disorders: patient characteristics and outcome.

OBJECTIVES: To provide an overview of a comprehensive and integrated case-management program that incorporates principles of assertive community treatment and combines effective medical and psychosocial interventions and to present the results of a process and outcome evaluation of the program, with particular emphasis on its impact on service utilization and consumer satisfaction. METHOD: Data on demographic, clinical, and several outcome measures were collected on all patients who received care in the program for a minimum of 6 months. For process evaluation we assessed the extent to which the program adhered to its goals and satisfied the patients, their families, and community-service agencies. Outcome-evaluation data on the number and length of hospital admissions were compared for each subject with individual historical data for a period equal to the time spent in the program. In addition, relapses of psychotic symptoms that did not result in hospital admissions were calculated for each patient while in the program. RESULTS: Demographic, clinical, and treatment characteristics of clients show that the program has succeeded in maintaining its focus on providing services to relatively chronically ill patients with psychotic disorders over a mean period of 3 years. The process-evaluation data indicated a high level of satisfaction by patients, families, and other service agencies with the services received. Information on outcome variable showed that the program achieved significantly lower rates of hospital admissions and relapse of psychosis than expected. There was a highly significant reduction achieved in the utilization of inpatient hospital resources for patients receiving care in the program. Most of the inpatient service utilization was attributed to patients either who were resistant to treatment with antipsychotic agents or who refused to accept or comply with medication. CONCLUSIONS: It is possible to provide effective continuity of care from inpatient treatment to community adjustment for most individuals with psychotic disorders across the spectrum by blending hospital and community resources within an integrated case-management model of care.

Adult↗