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Biomedical subjects

J Posnett

Publications and source records attributed to J Posnett.

17 recordsLinked to original sources
PubMed2003

The cost-effectiveness of fondaparinux compared with enoxaparin as prophylaxis against thromboembolism following major orthopedic surgery.

BACKGROUND: The selective antithrombotic fondaparinux is more effective than the low-molecular-weight heparin enoxaparin for prevention of venous thromboembolism (deep-vein thrombosis [DVT] or pulmonary embolism) in patients undergoing major orthopedic surgery, but its cost-effectiveness is undetermined. OBJECTIVES: To evaluate the cost-effectiveness of fondaparinux relative to enoxaparin as prophylaxis against venous thromboembolism (VTE) for patients undergoing total hip replacement, total knee replacement or hip fracture surgery in the UK. PATIENTS/METHODS: A decision analysis model was created simulating the impact of fondaparinux and enoxaparin on patient outcomes and costs over various time points up to 5 years following surgery. The main outcome measures were treatment costs per patient and the incidence of clinical VTE and VTE-related deaths. A weighted (combined) cohort reflects the proportion of patients undergoing these procedures in 2000/2001. RESULTS: In the combined cohort, compared with enoxaparin, fondaparinux is expected to produce 20 fewer clinical VTE events and 3.2 fewer VTE-related deaths per 1000 procedures at 5 years. Cost savings at 5 years are pound 27 per patient with fondaparinux (discounted at 6% per year). In each of the three surgical groups, fondaparinux leads to lower expected costs per patient and to a smaller number of VTE events and VTE-related deaths. RESULTS are sensitive to the price difference between fondaparinux and enoxaparin and variation in the rate of late DVT. The analysis is robust to variations in all other key parameters. CONCLUSIONS: Compared with enoxaparin, fondaparinux is more effective and reduces costs to the healthcare system. At current prices, fondaparinux is the recommended strategy in the UK for prophylaxis following major orthopedic surgery.

Anticoagulants↗
PubMed2002

Team approach versus ad hoc health services for young people with physical disabilities: a retrospective cohort study.

BACKGROUND: Young people with physical disabilities often have difficulty attaining independence in adult life and consequently need lifelong support from parents and from health-care and social-care services. There are concerns about the organisation and cost-effectiveness of such services and their ability to meet the independence training and serious health needs of these young people. Our aim was to compare a young adult team (YAT) approach with the ad hoc service approach in four locations in England, in terms of their ability to enhance the participation in society of these young people and their cost. METHODS: We did a retrospective cohort study, in which we interviewed 254 physically disabled young people. 124 healthy controls were given a questionnaire. We interviewed with standardised measures and used logistic regression analysis to test for effects of ad hoc and YAT services. The Mantel-Haenszel chi2 statistic was used to test for differences in resource use between areas in which the YAT and ad hoc services were available. FINDINGS: The absence of pain, fatigue, and stress increased the odds of participation two-fold to four-fold. After adjustment for these factors, young people cared for by multidisciplinary YAT teams were 2.54 times (95% CI 1.30-4.98) more likely than those who used ad hoc services to participate in society. Resource use did not differ between the two service types. INTERPRETATION: A YAT approach costs no more to implement than an ad hoc approach, and is more likely to enhance participation in society of young people with physical disabilities.

Adolescent↗
PubMed2001

Does general practitioner involvement in commissioning maternity care make a difference?

OBJECTIVES: To evaluate the impact of general practitioners' commissioning of maternity services on women's experiences of care and on resource use, and to consider the implications for primary care commissioning. METHOD: Comparison of women's experiences and resource use between 11 commissioning and 10 non-commissioning general practices. Face-to-face interviews with 212 staff in general practices, National Health Service trusts and health authorities between 1996 and 1998 to establish how maternity care was organised. Women's experience of information, choice, control and resource use obtained by questionnaire mailed 4 weeks post-partum. Data were analysed using multi-level modelling to adjust for case-mix differences. RESULTS: After two reminders, 1957 women (62%) responded to the questionnaire (inter-practice range 52-81%). There were no significant differences in women's experience of care or their resource use between commissioning and non-commissioning practices. Commissioning practices were more likely to be associated with more vertically integrated models of service organisation, but responses to only three of 21 questions about experience of information, choice and control over care, or about resource use, differed between the four models of service organisation identified. CONCLUSIONS: The expectation that giving primary care organisations responsibility for commissioning care will result in improved patients' experiences of care or better use of resources should be treated with caution. The presence of strong national policy may be equally important. Models of service organisation are not proxies for quality of care. The most powerful force shaping patients' experiences of care may be health care professionals' ability to translate national policy into local services.

Continuity of Patient Care↗
PubMed2000

Evaluation of the relative cost-effectiveness of treatments for infertility in the UK.

This paper aims to complement existing clinical guidelines by providing evidence of the relative cost-effectiveness of treatments for infertility in the UK. A series of decision-analytical models have been developed to reflect current diagnostic and treatment pathways for the five main causes of infertility. Data to populate the models are derived from a systematic review and routine National Health Service activity data, and are augmented with expert opinion. Costs are derived from an analysis of extra-contractual referral tariffs and private sector data. Sensitivity analysis has been carried out to take account of the uncertainty of model parameters and to allow results to be interpreted in the light of local circumstances. Results of the modelling exercise suggest in-vitro fertilization is the most cost-effective treatment option for severe tubal factors and endometriosis, with surgery the most cost-effective in the case of mild or moderate disease. Ovulatory factors should be treated medically with the addition of laparoscopic ovarian diathermy in the presence of polycystic ovarian syndrome. For other causes, stimulated intrauterine insemination (unexplained and moderate male factor) and stimulated donor intrauterine insemination (severe male) are cost-effective.

Cost-Benefit Analysis↗
PubMed2000

Cost-effectiveness modeling of Dermagraft for the treatment of diabetic foot ulcers in the french context.

To assess the cost-effectiveness of Dermagraft(R) (human dermal replacement) in the treatment of the diabetic foot ulcer, compared to standard treatment. A Markov model was developed, to simulate, over a 52-week period, the health status of a cohort of 100 patients with a diabetic foot ulcer treated either with conventional therapy or with Dermagraft(R). The considered health states were: healed, same site recurrence, unhealed not infected, cellulitis, osteomyelitis, amputation and death. Each week, the patient may progress among states according to a set of transition probabilities directly derived from the original clinical trial conducted in the USA. The cost of each health state was estimated by a Delphi panel of French diabetologists (direct costs only, valuated from a societal perspective). A sensitivity analysis was performed. The total number of healed ulcers included first ulcers healed (76.38% for Dermagraft(R) vs. 69.35% for standard treatment; median time to heal is 14-15 weeks for Dermagraft(R) compared with 28-29 weeks for standard treatment) plus recurrences which are subsequently healed within the 52-week period (14.29 for Dermagraft(R) vs. 25.09 for standard treatment; median time to heal is 3-4 weeks for Dermagraft(R) compared with 5-6 weeks for standard treatment). The average expected cost per treated patient (C/E) using standard treatment for the considered 52-week period is 47,418 FF vs. 54,384 FF for Dermagraft(R) (including 18,200 FF for Dermagraft(R) acquisition and 36,184 FF for standard treatment). Because Dermagraft(R) heals more ulcers within 52 weeks, the average cost per healed ulcer is lower (53,522 FF vs. 56,687 FF for standard treatment). The incremental cost-effectiveness ratio of Dermagraft(R) (DeltaC/DeltaE) equals 38,784 FF, indicating the extra investment that the decision-maker has to accept for an additional ulcer healed with Dermagraft(R) compared with conventional treatment.

Cost-Benefit Analysis↗
PubMed1999

Is hospital performance related to expenditure on management?

OBJECTIVES: Reducing the costs of management appears an easy target for those seeking to generate savings or to promote better spending in the National Health Service (NHS). However, an assessment of the appropriate amount of spending on management requires an evaluation of how much management contributes to organizational performance. METHODS: Using routinely available NHS acute hospital data, an econometric analysis was undertaken to test the hypothesis that there is a relationship between the proportion of a hospital's income spent on management and the performance of the hospital measured along three dimensions: the achievement of financial targets; performance against waiting time standards defined in the Patient's Charter; and costs of service provision. RESULTS: No general relationship was found between management costs and hospital performance. However, there was some evidence of a quadratic relationship between management spending and the amount of operating surplus generated and performance against the three-month waiting time standard for an inpatient admission specified in the Patient's Charter. These results suggest that performance returns reach an optimum when management expenditure is around 5-6% of hospital income. CONCLUSIONS: The evidence is not yet strong enough to draw a general conclusion that management costs in NHS acute hospitals are too high or that an undiscriminating reduction in management costs would have no detrimental effects on hospital performance. However, the findings should prompt managers to identify ways in which their activities are productive and how these can be measured, and what distinguishes effective from ineffective management.

Data Collection↗
PubMed1999

Comparative cost-effectiveness of four-layer bandaging in the treatment of venous leg ulceration.

This paper reports the results of an analysis designed to estimate the expected annual cost per patient of treating venous leg ulcers, and to evaluate the relative cost-effectiveness of a systematic treatment regimen using a four-layer compression bandaging system (Profore) compared with usual care. A Markov model has been developed which simulates the transition of patients between health states (healed and unhealed) over a 52-week period. Healing rates used in the model are derived from those reported in the literature. By running the model for a cohort of 100 patients over 52 weeks it is possible to estimate expected outcomes and annual budgetary costs for alternative treatment regimens. Results suggest that, when compared with usual care, a systematic treatment regimen using Profore is unambiguously more cost-effective. Patient outcomes are improved and annual treatment costs reduced. An important implication is that failure to co-ordinate treatment policies and to use the most cost-effective treatments may result in substantial inefficiency in the use of NHS resources. This inefficiency could represent the equivalent of between 350,000 Pounds and 1.08 million Pounds annually for a typical health authority.

Bandages↗
PubMed1998

Primary care groups. Growing pains.

The management costs of primary care groups are likely to be higher than envisaged. Duplication of all functions in all PCGs is likely to be more expensive than current health authority commissioning arrangements. In the long term, the most effective deployment of management costs will depend on deciding which PCG commissions what.

Budgets↗
PubMed1996

Programme budgeting and marginal analysis: an approach to priority setting in need of refinement.

Programme budgeting is enjoying a revival in the British National Health Service primarily because of its recent coupling with marginal analysis. As well as providing a means of mapping activity and expenditure from the institutions providing care to the population receiving it, programme budgeting and marginal analysis aim to assist strategic planning by indicating where net benefits might be increased by reallocating spending within programmes. However, the method to achieve this is not yet sufficiently refined and results to date have been mixed. In particular, the approach to identifying options for evaluation is flawed because of the importance attached to the role of 'expert' groups. A more systematic technique is suggested to overcome present methodological deficiencies.

Budgets↗
PubMed1992

The determinants and effects of health expenditure in developed countries.

Previous studies of international differences in health spending have been restricted to the use of relatively small samples of cross-sectional data. Our objective here is to re-examine the results of previous work using a sample of 560 pooled time-series and cross-section observations. Results confirm the importance of GDP as a determinant of health spending, with an estimated income elasticity at or around unity, but also suggest that OECD countries should not be regarded as a single, homogeneous group. The importance of some non-income variables is also confirmed, although the direct effect of these factors appears to be small.

Australia↗
PubMed1991

Pricing and openness in contracts for health care services.

This paper explores the objective of increased competition and considers whether different types of competition are likely to lead to desirable market outcomes. Potential sources of market failure, and hence inefficiency, are examined. The paper then considers what type and degree of regulation may be necessary if the forces of unrestrained competition cannot be expected to achieve desirable outcomes. A number of different options, ranging from minimal regulation to central pricing schedules, are then discussed. Consideration is given to whether openness in costing and/or pricing is necessary and desirable in both short and long term. The paper raises a number of practical problems which may be faced and suggests ways in which incentives can be created to mimic the characteristics of a competitive market.

Contract Services↗
PubMedDate not supplied

Indirect cost in economic evaluation: the opportunity cost of unpaid inputs.

Unpaid time represents a potentially significant input into the health production function. The paper sets out the basis for valuation of time inputs consistent with the notion of opportunity cost. Such analysis requires consideration of whether time displaced in the production of health involves lost work or lost leisure. Furthermore, because valuation of opportunity cost requires the consistent treatment of costs and benefits, the study also considers the valuation of outputs. The basis for valuing the shadow price of work time is examined by firstly assuming perfect competition. The analysis then considers the presence of monopoly and monopsony in product markets and income and sales taxes. The basis for valuing the shadow price of leisure ("leisure' being all uses of time except paid employment) is restricted to an examination of methods previously used to value unpaid housework. The two methods examined are the replacement cost and the opportunity cost method. As the methods are not equivalent, the circumstances where each is appropriate vary depending on whether the output lost in producing health is replaced. Although not set out as the primary focus of the paper, the issues surrounding the valuation of outputs generated by non-market and quasi-market activity are examined. In particular, where activities such as informal care result in indirect utility to the carers (and patients) themselves, it is likely the full market wage provides a lower bound estimate of the value of marginal benefit. Finally the paper provides a practical approach to examining opportunity cost of unpaid inputs consistent with the concepts set out in preceding sections.

Caregivers↗
PubMedDate not supplied

An economic approach to clinical trial design and research priority-setting.

Whilst significant advances have been made in persuading clinical researchers of the value of conducting economic evaluation alongside clinical trials, a number of problems remain. The most fundamental is the fact that economic principles are almost entirely ignored in the traditional approach to trial design. For example, in the selection of an optimal sample size no consideration is given to the marginal costs or benefits of sample information. In the traditional approach this can lead to either unbounded or arbitrary sample sizes. This paper presents a decision-analytic approach to trial design which takes explicit account of the costs of sampling, the benefits of sample information and the decision rules of cost-effectiveness analysis. It also provides a consistent framework for setting priorities in research funding and establishes a set of screens (or hurdles) to evaluate the potential cost-effectiveness of research proposals. The framework permits research priority setting based explicitly on the budget constraint faced by clinical practitioners and on the information available prior to prospective research. It demonstrates the link between the value of clinical research and the budgetary restrictions on service provision, and it provides practical tools to establish the optimal allocation of resources between areas of clinical research or between service provision and research.

Bayes Theorem↗