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Biomedical subjects

G Salkeld

Publications and source records attributed to G Salkeld.

At least 19 recordsLinked to original sources
PubMed2006

Consumer impact of an interactive decision aid for rectal cancer patients offered adjuvant therapy.

OBJECTIVE: There is increasing interest in the use of decision aids (DAs) to facilitate patient involvement in clinical decisions. This study explored the views of patients with colorectal cancer and participants in a community bowel screening service regarding an interactive DA concerning adjuvant treatment for rectal cancer, and the impact of the aid on knowledge, anxiety, attitudes and preferences for treatment options. METHOD: Fourteen patients with colorectal cancer participated in four focus groups. Eighty-nine participants in a community bowel screening service completed a questionnaire before and 1 week after viewing the DA. Thirty were randomly selected to participate in a telephone interview to obtain qualitative feedback about the DA. RESULTS: Focus group participants reported using information to evaluate their doctor's care and expertise, or to prepare themselves for future symptoms and side-effects. Most supported the use of a DA and preferred pie charts to convey risk information. Within the community sample, anxiety remained stable and knowledge increased after exposure to the DA. Almost all participants found the DA useful and easy to understand, and felt it would make the process of decision making easier. CONCLUSION: A DA regarding adjuvant therapy for rectal cancer appears to be valued and to produce positive outcomes. A randomized controlled trial of this intervention is now required.

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PubMed2005

Discrete-choice experiment to measure patient preferences for the surgical management of colorectal cancer.

BACKGROUND: Establishing trust between a patient and his or her surgeon is of paramount importance. The aim of this study was to assess the relative importance of the 'attributes of trust' between surgeon and patient with colorectal cancer. METHODS: A discrete-choice questionnaire was conducted with 60 men and 43 women who had completed primary treatment for colorectal cancer in two teaching hospitals in Sydney, Australia. RESULTS: Forty-seven of the 103 patients based their choice of surgical management on a single attribute and the remainder were willing to trade between different attributes. In order of importance, patients based their choice of surgical management on specialty training (beta coefficient = 0.83), surgeon's communication (beta = 0.82), type of hospital (beta = 0.72) and who decides treatment (beta = 0.01). Patients who were vigilant in their decision-making style and those who did not have tertiary education were more likely to change their preferences in the repeat interview. CONCLUSION: Clinicians may have a better chance of meeting a patient's expectations about the process of care if they assess the patient's desire for knowledge and give those who do not have tertiary education more time to assimilate information about their treatment.

Choice Behavior↗
PubMed2004

Economic impact of laparoscopic versus open abdominal rectopexy.

BACKGROUND: The introduction of new laparoscopic techniques has important cost implications. The aim of this study was to compare the cost effectiveness of laparoscopic rectopexy with that of open abdominal rectopexy for full-thickness rectal prolapse. METHODS: A cost effectiveness study was conducted alongside a randomized trial of laparoscopic versus open abdominal rectopexy. RESULTS: The efficacy trial demonstrated significant subjective and objective differences in favour of the laparoscopic technique. The mean operating time was 51 min longer for laparoscopic rectopexy than for the open procedure. Laparoscopic disposables incurred a mean cost of pound 291 per patient. The mean duration of hospital stay was significantly shorter for the laparoscopic group (P = 0.001). Laparoscopic rectopexy was associated with an overall mean cost saving of pound 357 (95 per cent confidence interval pound 164 to pound 592; P = 0.042) per patient. CONCLUSION: Laparoscopic rectopexy is associated with superior clinical outcomes and is cheaper than the open approach.

Cost-Benefit Analysis↗
PubMed2004

What constitutes success in preventive health care? A case study in assessing the benefits of hip protectors.

The economic success of preventive health programs is typically assessed by the net health-related utility gain or loss to society relative to the cost. Issues relating to the positive or negative utility associated with participating in a preventive health program are often ignored. However, it is likely that calls for informed consumer choice and respect for patient autonomy will provide an impetus to examine utility associated with the process and outcomes of preventive health programs. In this paper, we outline the nature of the ex ante and ex post perspective in evaluating benefits and the presence of process utility and the utility of gambling in individual's utility function for preventive health care. The implications of including process attributes and psychological states when assessing benefits to society are discussed in relation to an empirical study on the value of external hip protectors for the prevention of hip fractures. We demonstrate that wearing hip protectors and the psychological outcomes of being a participant in the program can have a significant impact on individual's assessment of the benefits. Furthermore, point of reference plays a crucial role in their valuation. Individuals who did not consent to participate in a trial of hip protectors valued all states significantly lower than those who did participate in the trial. We argue that the utility associated with adherence to the intervention is an important issue for preventive health policy. From the viewpoint of applied welfare economics, evaluation of preventive health programs should allow for both process and outcome utility when assessing benefits. In this context, success might be viewed as maximising the opportunity for individuals to make an informed choice.

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PubMed2004

Cost utility of screening and treatment for early age related macular degeneration with zinc and antioxidants.

AIM: To assess the cost effectiveness of high dose zinc and antioxidants for delaying and reducing the progression of early age related macular degeneration (AMD). BACKGROUND: AMD is the leading cause of severe vision impairment and blindness in older people throughout the developed world. It currently affects around 420 000 people in the United Kingdom. METHODS: A cost utility analysis (CUA) was conducted to estimate the cost per quality adjusted life year (QALY) for screening a cohort of men and women, aged 55 years and over, for early AMD and then treating them with zinc and antioxidants. The incremental CUA was based on a decision analytic model, comparing screening with a no screening comparator (current practice). Extensive one way sensitivity analysis of parameters was conducted to determine the robustness of the model. RESULTS: In this model the cost effectiveness of screening for early AMD was pound 22 722 per quality adjusted life year (QALY) saved. The cost per QALY decreased to pound 18 948 if photodynamic therapy with verteporfin savings were included. CONCLUSIONS: Screening for, and prophylactic treatment of, early AMD is estimated to cost around pound 22 700 per QALY saved. This cost falls within accepted levels to warrant further investigation. These findings have implications for ophthalmic practice and healthcare planning.

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PubMed2004

Cost utility of photodynamic therapy for predominantly classic neovascular age related macular degeneration.

BACKGROUND/AIM: Age related macular degeneration (AMD) is the leading cause of severe vision impairment and blindness in older people throughout the developed world and currently affects around 420 000 UK citizens. Choroidal neovascularisation (CNV) is treatable with photodynamic therapy (PDT) but is expensive at over pound 1200 per treatment. The aim of this study was to assess the cost utility of PDT for better eye, predominantly classic, subfoveal choroidal neovascular lesions secondary to AMD. METHODS: Cost utility analysis (CUA) was conducted to estimate the cost effectiveness of PDT for scenarios involving reasonable (6/12) and poor (6/60) visual acuity. The models incorporated data from the Treatment of Age-related Macular Degeneration with PDT (TAP) Study and patient based utilities. The incremental CUA was based on decision analytical models, comparing treatment to a placebo comparator. Extensive one way sensitivity analysis of parameters was conducted to determine the robustness of the model. A discount rate of 6% was used for costs and quality adjusted life years (QALY). RESULTS: Model 1: in people with reasonable initial visual acuity, the cost utility of treating applicable neovascular AMD lesions was pound 31 607 per QALY saved, with a sensitivity analysis range from pound 25 285 to pound 37 928. Model 2: in people with poor initial visual acuity, the cost utility was pound 63 214 per QALY saved, with a sensitivity analysis range from pound 54 183 to pound 75 856. CONCLUSIONS: PDT treatment is the only available treatment for some forms of neovascular ("wet") AMD. Under these assumptions, PDT can be considered moderately cost effective for those with reasonable visual acuity but less cost effective for those with initial poor visual acuity. These findings have implications for ophthalmic practice and healthcare planning.

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PubMed2003

Home bowel cancer tests and informed choice--is current information sufficient?

OBJECTIVES: To evaluate the type of information that is available to purchasers of home-based bowel cancer test kits. METHODS: Manufacturers, pharmacies and independent testing programs were contacted to obtain faecal occult blood test (FOBT) kits. State cancer organisations were contacted for information on bowel cancer screening. Information on bowel cancer, the FOBT kit, the testing process and potential benefits and harms of the screening process were assessed using guidelines provided by the UK General Medical Council (GMC). RESULTS: FOBT kits and cancer organisation information provided adequate information on the purpose of screening, the screening process itself and potential benefits, but provided no information concerning uncertainties of screening or potential harms. CONCLUSIONS: On the basis of both the UK GMC criteria and patient desires for information, the information available at present falls short of being considered adequate for an informed decision to purchase a home-based FOBT. IMPLICATIONS: We must ensure adequate and balanced information is available to redress the present information asymmetry to facilitate informed participation in a potentially valuable public health initiative.

Australia↗
PubMed2003

A randomised trial of hip protector use by frail older women living in their own homes.

OBJECTIVES: To investigate the efficacy and effectiveness of hip protectors in frail community living older women. DESIGN: Randomised controlled trial. SETTING: Aged care health services in New South Wales, Australia. PATIENTS: 600 women 74 years of age or more (mean age 83 years), who had two or more falls or one fall requiring hospital admission in the previous year, and who lived in their own homes. INTERVENTION: Use of hip protectors. MAIN OUTCOME MEASURES: Adherence with use of hip protectors, falls, incidence of hip fracture, and adverse effects of use of hip protectors. RESULTS: Adherence was approximately 53% over the duration of the study and hip protectors were worn at the time of 51% of falls in the intervention group. The risk of hip fracture when falling while wearing hip protectors, compared with a fall with no hip protectors in place, was significantly reduced (relative risk (RR) 0.23, 95% confidence interval (CI) 0.08 to 0.67). On an intention to treat analysis, 21 and 22 hip fractures occurred in the intervention and control groups respectively (adjusted RR 0.92, 95% CI 0.51 to 1.68). Three users of hip protectors sustained a hip fracture while wearing properly applied protectors, while 16 hip protector users (5%) developed minor local complications. CONCLUSIONS: Hip protectors prevent hip fractures in community dwelling older women if worn at the time of a fall. The overall effectiveness of hip protectors was not established in this study, because of incomplete adherence with use of the protectors, and limited statistical power.

Accidental Falls↗
PubMed2000

Quality of life related to fear of falling and hip fracture in older women: a time trade off study.

OBJECTIVE: To estimate the utility (preference for health) associated with hip fracture and fear of falling among older women. DESIGN: Quality of life survey with the time trade off technique. The technique derives an estimate of preference for health states by finding the point at which respondents show no preference between a longer but lower quality of life and a shorter time in full health. SETTING: A randomised trial of external hip protectors for older women at risk of hip fracture. PARTICIPANTS: 194 women aged >/= 75 years enrolled in the randomised controlled trial or who were eligible for the trial but refused completed a quality of life interview face to face. OUTCOME MEASURES: Respondents were asked to rate their own health by using the Euroqol instrument and then rate three health states (fear of falling, a "good" hip fracture, and a "bad" hip fracture) by using time trade off technique. RESULTS: On an interval scale between 0 (death) and 1 (full health), a "bad" hip fracture (which results in admission to a nursing home) was valued at 0.05; a "good" hip fracture (maintaining independent living in the community) 0.31, and fear of falling 0.67. Of women surveyed, 80% would rather be dead (utility=0) than experience the loss of independence and quality of life that results from a bad hip fracture and subsequent admission to a nursing home. The differences in mean utility weights between the trial groups and the refusers were not significant. A test-retest study on 36 women found that the results were reliable with correlation coefficients within classes ranging from 0.61 to 0.88. CONCLUSIONS: Among older women who have exceeded average life expectancy, quality of life is profoundly threatened by falls and hip fractures. Older women place a very high marginal value on their health. Any loss of ability to live independently in the community has a considerable detrimental effect on their quality of life.

Accidental Falls↗
PubMed2000

The veil of experience: do consumers prefer what they know best?

There is growing interest from health policy makers in eliciting consumer preferences for health care services. This is particularly the case when assessing the likely impact of innovations. Some people may be wary of innovations because they prefer the service they have previously experienced. Consumer preferences for an existing and a hypothetical new bowel cancer testing programme were measured using a discrete choice experiment questionnaire. The results showed that consumers had a statistically significant preference for the existing service (status quo) when all other factors remained constant. It suggested that consumers make decisions under a 'veil of experience'. Possible explanations for this result include the endowment effect, status quo bias and loss aversion. Future evaluations of health service innovation should be aware of this tendency to favour the status quo.

Attitude to Health↗
PubMed2000

Hip protectors improve falls self-efficacy.

OBJECTIVES: To investigate the effect of use of external hip protectors on subjects' fear of falling and falls self-efficacy (belief in their own ability to avoid falling). DESIGN: Randomized controlled trial. SETTING: Aged-care health services in Sydney, Australia. PARTICIPANTS: 131 women aged 75 years or older, who had two or more falls or one fall requiring hospital admission in the previous year and who live at home. Sixty-one subjects were in the intervention group and 70 in the control group. INTERVENTION: Use of external hip protectors and encouragement to use the protectors by an adherence nurse. MEASUREMENTS: At the time of enrolment into a wider study examining the effect of hip protectors on hip fractures, participants recruited at home completed an assessment of fear of falling and falls efficacy as measured by the Falls Efficacy Scale and the Modified Falls Efficacy Scale. At 4-month follow-up, these scales were readministered by an observer who was not aware of the allocation of the participant to intervention or control groups. RESULTS: Fear of falling and falls self-efficacy, as measured by the Falls Efficacy and Modified Falls Efficacy Scales, were similar at baseline in both groups. Fear of falling was present at follow-up in 43% of subjects using hip protectors and 57% of the control group (chi2 = 2.58, P = 0.11). Hip protector users had greater improvement in falls self-efficacy at follow-up as measured by the Falls Efficacy Scale (t = 2.44, P = 0.016) and the Modified Falls Efficacy Scale (t = 2.08, P = 0.039). CONCLUSION: Hip protectors improve falls self-efficacy. As users of hip protectors feel more confident that they can complete tasks safely, they may become more physically active and require less assistance with activities of daily living.

Accidental Falls↗
PubMed2000

Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission.

BACKGROUND: The aim of this study was to assess the impact of fear of falling on the health of older people. METHODS: A total of 528 subjects (mean age 77 years) were recruited from two hospitals in Sydney, Australia, and followed for approximately 12 months. Eighty-five subjects died during follow-up, and 31 were admitted to an aged care institution. Tinetti's Falls Efficacy Scale (FES) was successfully administered to 418 subjects as part of the baseline assessment. Among those with baseline FES scores, ability to perform 10 activities of daily living (ADLs) was assessed at baseline and follow-up in 307 subjects, and SF-36 scores were assessed at baseline and follow-up in 90 subjects recruited during the latter part of the study. Falls during follow-up were identified using a monthly falls calendar. RESULTS: Compared with those with a high fall-related self-efficacy (FES score = 100), those with a low fall-related self-efficacy (FES score < or = 75) had an increased risk of falling (adjusted relative risk 2.09, 95% confidence interval [CI] 1.31-3.33). Those with poorer fall-related self-efficacy had greater declines in ability to perform ADLs (p < .001): the total ADL score decreased by 0.69 activities among persons with low FES scores (< or =75) but decreased by only 0.04 activities among persons with FES scores of 100. Decline in ADLs was not explained by the higher frequency of falls among persons with low FES scores. SF-36 scores (particularly scores on the Physical Function and Bodily Pain subscales) tended to decline more among persons with poor fall-related self-efficacy. Nonfallers who said they were afraid of falling had an increased risk of admission to an aged care institution. CONCLUSIONS: Fear of falling has serious consequences for older people. Interventions that successfully reduce fear of falling and improve fall-related self-efficacy are likely to have major health benefits.

Accidental Falls↗
PubMed2000

The cost effectiveness of a home hazard reduction program to reduce falls among older persons.

BACKGROUND: The effectiveness of individual components (other than exercise) of multifactorial intervention packages aimed to reduce the incidence of falls in older people is uncertain. There have been no randomised trials of home modifications alone for the prevention of falls. OBJECTIVES: To estimate the cost-effectiveness of just one component of a multifactorial approach to falls prevention, that is, a home hazard reduction program. The study estimates the size and direction of change in resource use within and between the hospital, home and community sectors. METHODS: A randomised trial was conducted to evaluate the effectiveness of home modifications for prevention of falls among older people. An occupational therapist (O/T) with experience in aged care assessed homes for environmental hazards and supervised the necessary home modifications. SUBJECTS: The subjects in this study were people aged 65 years and older and most were recruited during a hospital stay. The cost-effectiveness analysis was based on a randomised trial with a total of 530 subjects. RESULTS: The incremental cost per fall prevented was $4,986. A sensitivity analysis was conducted by removing 12 outlier subjects (6 control and 6 intervention). The incremental cost per fall prevented was $1,921 for all subjects and was cost saving for subjects who had fallen in the 12 months prior to randomisation. CONCLUSIONS & IMPLICATIONS: A single factor home hazard reduction program is more likely to be most cost-effective amongst older people who have a history of falls.

Accidental Falls↗
PubMed1999

Home visits by an occupational therapist for assessment and modification of environmental hazards: a randomized trial of falls prevention.

OBJECTIVE: To determine whether occupational therapist home visits targeted at environmental hazards reduce the risk of falls. DESIGN: A randomized controlled trial. SETTING: Private dwellings in the community in Sydney, Australia. PARTICIPANTS: A total of 530 subjects (mean age 77 years), recruited primarily before discharge from selected hospital wards. INTERVENTION: A home visit by an experienced occupational therapist, who assessed the home for environmental hazards and facilitated any necessary home modifications. MEASUREMENTS: The primary study outcome was falls, ascertained over a 12-month follow-up period using a monthly falls calendar. RESULTS: Thirty six percent of subjects in the intervention group had at least one fall during follow-up, compared with 45% of controls (P = .050). The intervention was effective only among subjects (n = 206) who reported having had one or more falls during the year before recruitment into the study; in this group, the relative risk of at least one fall during follow-up was 0.64 (95% confidence interval, 0.50-0.83). Similar results were obtained when falls data were analyzed using survival analysis techniques (proportional and multiplicative hazards models) and fall rates (mean number of falls per person per year). About 50% of the recommended home modifications were in place at a 12-month follow-up visit. CONCLUSIONS: Home visits by occupational therapists can prevent falls among older people who are at increased risk of falling. However, the effect may not be caused by home modifications alone. Home visits by occupational therapists may also lead to changes in behavior that enable older people to live more safely in both the home and the external environment.

Accidental Falls↗
PubMed1998

What are the benefits of preventive health care?

In most forms of evaluation the benefits of preventive health care are narrowly defined in terms of reductions in future morbidity and mortality. Thus it is normally assumed that it is the final health gains alone which bear utility. This discounts the possibility that individuals may derive utility from the process of health care and other outcomes as well as the end health states. Attributes such as anxiety, reassurance, autonomy, regret and hope provide potential benefits or disbenefits in addition to health gains. This paper explores the concept of process utility in the specific context of preventive goods. Characteristics such as information, awareness and autonomy are examined for two preventive goods--hip protectors and mammographic screening. If individuals trade off process attributes for final health outcomes, then to ignore process utility may lead to a sub-optimal allocation of resources.

Aged↗