Biomedical subjects

J Ratcliffe

Publications and source records attributed to J Ratcliffe.

At least 19 recordsLinked to original sources

PubMed2006

A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis.

OBJECTIVE: To evaluate the cost effectiveness of acupuncture in the management of persistent non-specific low back pain. DESIGN: Cost effectiveness analysis of a randomised controlled trial. SETTING: Three private acupuncture clinics and 18 general practices in York, England. PARTICIPANTS: 241 adults aged 18-65 with non-specific low back pain of 4-52 weeks' duration. INTERVENTIONS: Ten individualised acupuncture treatments over three months from acupuncturists trained in traditional Chinese medicine (n = 160) or usual care only (n = 81). MAIN OUTCOME MEASURE: Incremental cost per quality adjusted life year (QALY) gained over two years. RESULTS: Total costs to the United Kingdom's health service during the two year study period were higher on average for the acupuncture group (460 pounds sterling; 673 euros; 859 dollars) than for the usual care group (345 pounds sterling) because of the costs associated with initial treatment. The mean incremental health gain from acupuncture at 12 months was 0.012 QALYs (95% confidence interval -0.033 to 0.058) and at 24 months was 0.027 QALYs (-0.056 to 0.110), leading to a base case estimate of 4241 pounds sterling per QALY gained. This result was robust to sensitivity analysis. The probabilistic sensitivity analysis showed acupuncture to have a more than 90% chance of being cost effective at a pound20 000 cost per QALY threshold. CONCLUSION: A short course of traditional acupuncture for persistent non-specific low back pain in primary care confers a modest health benefit for minor extra cost to the NHS compared with usual care. Acupuncture care for low back pain seems to be cost effective in the longer term. TRIAL REGISTRATION: ISRCTN80764175 [controlled-trials.com].

Acupuncture Therapy↗

PubMed2006

Cost-effectiveness analysis of surgery versus conservative treatment for uncomplicated varicose veins in a randomized clinical trial.

BACKGROUND: Despite being a common procedure, the cost effectiveness of surgery for varicose veins has not been established. METHODS: Cost-effectiveness analysis was carried out alongside a randomized clinical trial at two vascular units within National Health Service (NHS) hospitals. Some 246 patients with uncomplicated varicose veins and evidence of saphenofemoral or saphenopopliteal reflux were allocated randomly to receive either conservative management or surgical treatment. Incremental cost per quality-adjusted life year (QALY) gained at 24 months following randomization was calculated. RESULTS: Total NHS costs during the 2-year study period were higher for the surgically treated group (733 UK pounds) than for those who had conservative treatment (345 UK pounds). The difference in costs was statistically significant. The mean incremental health gain from surgical treatment at 24 months was 0.083 QALYs, leading to a base-case estimate of 4682 UK pounds per QALY gained. Assuming an implicit threshold maximum willingness-to-pay value of 20 000 UK pounds for a QALY, the probability of surgical treatment for varicose veins falling below this threshold value was 70 per cent. This result was found to be robust to sensitivity analysis. CONCLUSION: For patients with uncomplicated varicose veins and evidence of saphenofemoral or saphenopopliteal reflux, surgical treatment for varicose veins offers a modest health benefit for relatively little additional NHS cost relative to conservative treatment.

Cost-Benefit Analysis↗

PubMed2006

Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins.

BACKGROUND: Surgical treatment of medically uncomplicated varicose veins is common, but its clinical effectiveness remains uncertain. METHODS: A randomized clinical trial was carried out at two large acute National Health Service hospitals in different parts of the UK (Sheffield and Exeter). Some 246 patients were recruited from 536 consecutive referrals to vascular outpatient clinics with uncomplicated varicose veins suitable for surgical treatment. Conservative management, consisting of lifestyle advice, was compared with surgical treatment (flush ligation of sites of reflux, stripping of the long saphenous vein and multiple phlebectomies, as appropriate). Changes in health status were measured using the Short Form (SF) 6D and EuroQol (EQ) 5D, quality of life instruments based on SF-36 and EuroQol, complications of treatment, symptomatic measures, anatomical extent of varicose veins and patient satisfaction. RESULTS: In the first 2 years after treatment there was a significant quality of life benefit for surgery of 0.083 (95 per cent confidence interval (c.i.) 0.005 to 0.16) quality-adjusted life years (QALYs) based on the SF-6D score and 0.13 (95 per cent c.i. 0.016 to 0.25) based on the EQ-5D score. Significant benefits were also seen in symptomatic and anatomical measures. CONCLUSION: Surgical treatment provides symptomatic relief and significant improvements in quality of life in patients referred to secondary care with uncomplicated varicose veins.

Exercise Therapy↗

PubMed2006

The evolution of the emergency care practitioner role in England: experiences and impact.

BACKGROUND: The emergency care practitioner (ECP) is a generic practitioner who combines extended nursing and paramedic skills. The "new" role emerged out of changing workforce initiatives intended to improve staff career opportunities in the National Health Service and ensure that patients' health needs are assessed appropriately. OBJECTIVE: To describe the development of ECP Schemes in 17 sites, identify criteria contributing to a successful operational framework, analyse routinely collected data and provide a preliminary estimate of costs. METHODS: There were three methods used: (a) a quantitative survey, comprising a questionnaire to project leaders in 17 sites, and analysis of data collected routinely; (b) qualitative interpretation based on telephone interviews in six sites; and (c) an economic costing study. RESULTS: Of 17 sites, 14 (82.5%) responded to the questionnaire. Most ECPs (77.4%) had trained as paramedics. Skills and competencies have been extended through educational programmes, training, and assessment. Routine data indicate that 54% of patient contacts with the ECP service did not require a referral to another health professional or use of emergency transport. In a subset of six sites, factors contributing to a successful operational framework were strategic visions crossing traditional organisational boundaries and appropriately skilled workforce integrating flexibly with existing services. Issues across all schemes were patient safety, appropriate clinical governance, and supervision and workforce issues. On the data available, the mean cost per ECP patient contact is 24.00 pounds sterling, which is less than an ED contact of 55.00 pounds sterling. CONCLUSION: Indications are that the ECP schemes are moving forward in line with original objectives and could be having a significant impact on the emergency services workload.

Delivery of Health Care↗

PubMed2006

Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial).

OBJECTIVES: To establish the cost-effectiveness of surgery and sclerotherapy for the treatment of varicose veins. DESIGN: Randomised controlled trials (RCTs) were carried out for conservative treatment, sclerotherapy and surgery for varicose veins. An economic analysis was carried out alongside the randomised trial. Economic modelling was undertaken based on the primary data collection and a literature review (database searches undertaken in April 2000 and updated in March 2001). SETTING: Primary data collection was from a large district general hospital and a teaching hospital both in England over a 2-year period from January 1999. Cost-effectiveness analysis and economic modelling were carried out using an NHS perspective. PARTICIPANTS: A total of 1009 patients were recruited. INTERVENTIONS: Thirty-four patents were randomised in Group 1 (minor varicose veins with no reflux, randomised between conservative treatment and sclerotherapy), 77 in Group 2 (moderate varicose veins with reflux, randomised between surgery and sclerotherapy) and 246 in Group 3 (severe varicose veins with reflux, randomised between conservative treatment and surgery). The remaining 652 patients formed the observational part of the study. MAIN OUTCOME MEASURES: The cost-effectiveness analysis was based on NHS treatment costs for the 2002--3 financial year, and utilities based on the Short Form 6D (SF-6D) preference-based health measure. For the clinical trial, the outcome measures were health-related quality of life (HRQoL) [Short Form with 36 Items (SF-36), EuroQol quality of life questionnaire (EQ-5D), visual analogue scale (VAS) and standard gamble], symptomatic relief, anatomical extent (for which a new classification was developed and validated), patient satisfaction and the incidence of complications. RESULTS: Of the RCTs, only the Group 3 trial was large enough to provide clear results. This showed that surgical treatment produced better results than conservative treatment in terms of HRQoL, symptomatic relief, anatomical extent and patient satisfaction. Clinical outcomes of surgery and sclerotherapy showed significant improvement in the extent of varicose veins, symptomatic and HRQoL parameters. Cost-effectiveness analysis based on the Group 3 trial showed that the surgery produced an estimated discounted benefit of 0.054 quality-adjusted life-year (QALY) over a 2-year period, with an additional discounted cost of pound 387.45, giving an incremental cost-effectiveness ratio (ICER) of pound 7175 per QALY. Economic modelling suggested that surgery produced a still greater benefit when considered with a 10-year time horizon, with an ICER of pound 1936 per QALY. Injection sclerotherapy produced an incremental benefit of approximately 0.044 QALY at a cost of pound 155 when compared with conservative treatment, giving an ICER of pound 3500 per QALY. When surgery was compared with sclerotherapy, surgery produced greater benefit with a lower ICER (showing extended dominance). CONCLUSIONS: Standard surgical treatment of varicose veins by saphenofemoral ligation, stripping and multiple phlebectomies is a clinically effective and cost-effective treatment for varicose veins, with an ICER well below the threshold normally considered appropriate for the funding of treatments within the NHS. Injection sclerotherapy also appears to be cost-effective, but produces less overall benefit, with a higher ICER than surgery for patients with superficial venous reflux. In minor varicose veins without reflux, sclerotherapy is likely to provide a small average benefit with acceptable cost-effectiveness. Research is needed into methods for accurate and acceptable utility evaluations for conditions with relatively minor effect on HRQoL and also for a validated and standardised method of classification for varicose veins.

Adolescent↗

PubMed2005

Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain.

OBJECTIVES: To test whether patients with persistent non-specific low back pain, when offered access to traditional acupuncture care alongside conventional primary care, gained more long-term relief from pain than those offered conventional care only, for equal or less cost. Safety and acceptability of acupuncture care to patients, and the heterogeneity of outcomes were also tested. DESIGN: A pragmatic, two parallel group, randomised controlled trial. Patients in the experimental arm were offered the option of referral to the acupuncture service comprising six acupuncturists. The control group received usual care from their general practitioner (GP). Eligible patients were randomised in a ratio of 2:1 to the offer of acupuncture to allow between-acupuncturist effects to be tested. SETTING: Three non-NHS acupuncture clinics, with referrals from 39 GPs working in 16 practices in York, UK. PARTICIPANTS: Patients aged 18-65 years with non-specific low back pain of 4-52 weeks' duration, assessed as suitable for primary care management by their general practitioner. INTERVENTIONS: The trial protocol allowed up to ten individualised acupuncture treatments per patient. The acupuncturist determined the content and the number of treatments according to patient need. MAIN OUTCOME MEASURES: The Short Form 36 (SF-36) Bodily Pain dimension (range 0-100 points), assessed at baseline, and 3, 12 and 24 months. The study was powered to detect a 10-point difference between groups at 12 months post-randomisation. Cost--utility analysis was conducted at 24 months using the EuroQoL 5 Dimensions (EQ-5D) and a preference-based single index measure derived from the SF-36 (SF-6D). Secondary outcomes included the McGill Present Pain Index (PPI), Oswestry Pain Disability Index (ODI), all other SF-36 dimensions, medication use, pain-free months in the past year, worry about back pain, satisfaction with care received, and safety and acceptability of acupuncture care. RESULTS: A total of 159 patients were in the 'acupuncture offer' arm and 80 in the 'usual care' arm. All 159 patients randomised to the offer of acupuncture care chose to receive acupuncture treatment, and received an average of eight acupuncture treatments within the trial. Analysis of covariance, adjusting for baseline score, found an intervention effect of 5.6 points on the SF-36 Pain dimension [95% confidence interval (CI) -1.3 to 12.5] in favour of the acupuncture group at 12 months, and 8 points (95% CI 0.7 to 15.3) at 24 months. No evidence of heterogeneity of effect was found for the different acupuncturists. Patients receiving acupuncture care did not report any serious or life-threatening events. No significant treatment effect was found for any of the SF-36 dimensions other than Pain, or for the PPI or the ODI. Patients receiving acupuncture care reported a significantly greater reduction in worry about their back pain at 12 and 24 months compared with the usual care group. At 24 months, the acupuncture care group was significantly more likely to report 12 months pain free and less likely to report the use of medication for pain relief. The acupuncture service was found to be cost-effective at 24 months; the estimated cost per quality-adjusted (QALY) was 4241 pounds sterling (95% CI 191 pounds sterling to 28,026 pounds sterling) using the SF-6D scoring algorithm based on responses to the SF-36, and 3598 pounds sterling (95% CI 189 pounds sterling to 22,035 pounds sterling) using the EQ-5D health status instrument. The NHS costs were greater in the acupuncture care group than in the usual care group. However, the additional resource use was less than the costs of the acupuncture treatment itself, suggesting that some usual care resource use was offset. CONCLUSIONS: Traditional acupuncture care delivered in a primary care setting was safe and acceptable to patients with non-specific low back pain. Acupuncture care and usual care were both associated with clinically significant improvement at 12- and 24-month follow-up. Acupuncture care was significantly more effective in reducing bodily pain than usual care at 24-month follow-up. No benefits relating to function or disability were identified. GP referral to a service providing traditional acupuncture care offers a cost-effective intervention for reducing low back pain over a 2-year period. Further research is needed to examine many aspects of this treatment including its impact compared with other possible short-term packages of care (such as massage, chiropractic or physiotherapy), various aspects of cost-effectiveness, value to patients and implementation protocols.

Acupuncture Therapy↗

PubMed2003

Patients' preferences for characteristics associated with treatments for osteoarthritis.

OBJECTIVE: The purpose of this study was to investigate patient preferences for attributes associated with the efficacy and side-effects of treatment for osteoarthritis. METHODS: A stated preference design questionnaire was administered to a sample of 412 individuals diagnosed with osteoarthritis (OA). RESULTS: Statistically significant attributes in influencing treatment preferences were the level of joint aches, the level of physical mobility and the risk of experiencing serious side-effects from treatment. Respondents were relatively more concerned about the risk of serious side-effects (even with a very low probability) than mild to moderate side-effects (at a much higher probability). Data segmentation revealed some variations in preferences according to respondent characteristics. The importance of joint aches increased according to the severity of the symptoms of osteoarthritis, indicating that this attribute is more troublesome to those respondents with more severe symptoms. Older respondents were more willing than younger respondents to accept an increased risk of experiencing serious side-effects for an improvement in the symptoms of OA. Individuals in lower income brackets appeared to attach greater importance to joint aches and the level of mobility experienced than those in higher income brackets. Respondents who had previously experienced gastrointestinal side-effects from treatment were, as expected, more tolerant of them than those who had not. CONCLUSION: The use of conjoint analysis to assess patient preferences provides a useful insight to the likely attitudes of patients to novel treatments for osteoarthritis.

Age Factors↗

PubMed2003

Cluster analysis of symptoms and health seeking behaviour differentiates subgroups of patients with severe irritable bowel syndrome.

BACKGROUND: Irritable bowel syndrome (IBS) is a heterogeneous condition which is diagnosed according to specific bowel symptom clusters. The aim of the present study was to identify subgroups of IBS subjects using measures of rectal sensitivity and psychological symptoms, in addition to bowel symptoms. Such groupings, which cross conventional diagnostic approaches, may provide greater understanding of the pathogenesis of the condition and its treatment. METHOD: A K means cluster analysis was used to group 107 clinic patients with IBS according to physiological, physical, and psychological parameters. All patients had severe IBS and had failed to respond to usual medical treatment. Twenty nine patients had diarrhoea predominant IBS, 26 constipation predominant, and 52 had an alternating bowel habit. RESULTS: The clusters were most clearly delineated by two variables: "rectal perceptual threshold (volume)" and "number of doctor visits". Three subgroups were formed. Group I comprised patients with low distension thresholds and high rates of psychiatric morbidity, doctor consultations, interpersonal problems, and sexual abuse. Group II also had low distension thresholds but low rates of childhood abuse and moderate levels of psychiatric disorders. Group III had high distension thresholds, constipation or alternating IBS, and low rates of medical consultations and sexual abuse. CONCLUSION: The marked differences across the three groups suggest that each may have a different pathogenesis and respond to different treatment approaches. Inclusion of psychosocial factors in the analysis enabled more clinically meaningful groups to be identified than those traditionally determined by bowel symptoms alone or rectal threshold.

Adult↗

PubMed2002

Assessing patients' preferences for characteristics associated with homeopathic and conventional treatment of asthma: a conjoint analysis study.

BACKGROUND: A study was undertaken to investigate the preferences of patients with asthma for attributes or characteristics associated with treatment for their asthma and to investigate the extent to which such preferences may differ between patient subgroups. METHODS: The economic technique of conjoint analysis (CA) was used to investigate patients' strength of preference for several key attributes associated with services for the treatment of asthma. A CA questionnaire was administered to two groups of asthma outpatients aged 18 years or older, 150 receiving conventional treatment at Whipps Cross Hospital (WC) and 150 receiving homeopathic treatment at the Royal London Homoeopathic Hospital (RL). RESULTS: An overall response rate of 47% (n=142) was achieved. Statistically significant attributes in influencing preferences for both the WC and RL respondents were (1) the extent to which the doctor gave sufficient time to listen to what the patient has to say, (2) the extent to which the treatment seemed to relieve symptoms, and (3) the travel costs of attending for an asthma consultation. The extent to which the doctor treated the patient as a whole person was also a statistically significant attribute for the RL respondents. CONCLUSIONS: This study has shown that aspects associated with the process of delivery of asthma services are important to patients in addition to treatment outcomes. The homeopathic respondents expressed stronger preferences for the doctor to treat them as a whole person than the patients receiving conventional treatment. Overall, the preferences for the attributes included in the study were similar for both groups.

Adult↗

PubMed2001

Enteral human IgG for prevention of necrotising enterocolitis: a placebo-controlled, randomised trial.

BACKGROUND: Neonatal necrotising enterocolitis is a serious, commonly fatal disease in premature neonates. Although feeding with expressed breast milk and other good nursery practices are partly protective, preventive measures are needed. Treating neonates enterally with a mixture of human IgA and IgG, prepared from donated blood, has been claimed to protect against necrotising enterocolitis. However, no IgA preparation is available in Australia. Our aim, therefore, was to identify whether or not enteral IgG could prevent the disorder. METHODS: We did a multicentre, double-blind, placebo- controlled trial. We randomly assigned 768 infants to receive human IgG 1200 mg/kg daily, and 761 to receive placebo, for up to 28 days. Treatment began at the same time as enteral feeding. The primary outcome measure was the proportion of infants who developed definite necrotising enterocolitis during the trial, and any deaths that resulted from the disorder in the treatment and placebo groups. Analysis was on an intention-to-treat basis. FINDINGS: 43 infants developed definite necrotising enterocolitis in the IgG group, ten of whom died. In the placebo group, 41 infants contracted the disorder and six died (p=0.47). 25 infants on IgG and 36 on placebo had suspect necrotising enterocolitis (p=0.14). INTERPRETATION: Supplementation of enteral feeds with human IgG does not reduce necrotising enterocolitis.

Double-Blind Method↗

PubMed2001

Health-related quality of life and health care costs in severe, refractory irritable bowel syndrome.

BACKGROUND: The irritable bowel syndrome (IBS) may lead to considerable impairment of health-related quality of life and high health care costs. It is not clear whether these poor outcomes directly result from severe bowel symptoms or reflect a coexisting psychiatric disorder. OBJECTIVE: To determine whether bowel symptom severity and psychological symptoms directly influence health-related quality of life and health care costs. DESIGN: Cross-sectional survey. SETTING: Secondary and tertiary gastroenterology clinics. PATIENTS: 257 patients with severe IBS who did not respond to usual treatments and were recruited for a trial of psychological treatment. MEASUREMENTS: Predictors were abdominal pain, entries in a diary of 10 IBS symptoms, and measures of psychological symptoms. Outcomes were inability to work, health-related quality of life (measured by Medical Outcomes Survey 36-item short-form questionnaire [SF-36] physical component summary scores), and health care and productivity costs. Predictor and outcome measures were compared by using multiple regression and logistic regression analyses. RESULTS: Abdominal pain occurred on average 24 days per month and activities were restricted on 145 days of the previous 12 months. The mean (+/-SD) Hamilton depression score was 11.3 +/- 6.1. The SF-36 physical component summary score was low (37.7 +/- 10.6), and the patients had incurred high health care costs ($1743 +/- $2263) over the previous year. Global severity and somatization scores on the Symptom Checklist 90 Revised, abdominal pain, and Hamilton depression scores independently contributed to the physical component score of the SF-36 (adjusted R(2) = 35.2%), but only psychological scores were associated with disability due to ill health. These variables did not accurately predict health care or other costs (adjusted R(2) = 9.3%). History of sexual abuse was not an independent predictor of outcome. CONCLUSIONS: Both abdominal and psychological symptoms are independently associated with impaired health-related quality of life in patients with severe IBS. Optimal treatment is likely to require a holistic approach. Since health care and loss of productivity costs are not clearly associated with these symptoms, alleviation of them will not necessarily lead to reduced costs.

Abdominal Pain↗

PubMed2001

A simulation modelling approach to evaluating alternative policies for the management of the waiting list for liver transplantation.

A shortage of donor liver grafts unfortunately results in approximately 10% of patients dying whilst listed for a liver transplant in Europe and the United States. Thus it is imperative that all available organs are used as efficiently as possible. This paper reports upon the application of a simulation modelling approach to assess the impact of several alternative allocation policies upon the cost effectiveness of this technology at one liver transplant centre in the UK. The impact of changes in allocation criteria on the estimated net life expectancy, average net costs and overall cost effectiveness of the transplantation programme were evaluated. The incremental cost effectiveness ratio (ICER) for the base case allocation policy, based upon the time spent on the waiting list (i.e., longest wait first) was 11,557 pounds sterling at 1999 prices. The ICERs associated with an allocation policy based upon age (lowest age first), and an allocation policy based upon the severity of the pre-transplant condition of the patient (with most severely ill patients given a lower priority) were lower than the base case at 10,424 pounds sterling and 9,077 pounds sterling, respectively. The results of this modelling study suggest that the overall cost effectiveness of the liver transplantation programme could be improved if the current allocation policy were modified to give more weight to the age of the patient and the reduced chances of success of the most severely ill patients.

Cost-Benefit Analysis↗

PubMed2001

Investigating women's preferences for intrapartum care: home versus hospital births.

There is an increasing amount of evidence to suggest that the clinical outcomes associated with a home birth for low risk women are at least as good, if not better than, the clinical outcomes associated with giving birth in hospital. If it is the case that there is little or no difference in clinical outcomes between the two modes of delivery, then traditional measures of benefit used in health economics, e.g. quality adjusted life years (QALYs), would detect little or no difference between the alternative modes of delivery. From this, the conclusion would be that the utility values associated with each mode of delivery are similar. However, women may still have clearly defined preferences relating to the way in which maternity care is provided. This paper uses the economic technique of conjoint analysis to assess the relative value attached to several main characteristics associated with the process of maternity care during the intrapartum stage for women who have actively chosen to give birth at home relative to women who have given birth in hospital. It was found that respondents who had chosen a home birth valued continuity of carer, a homely environment and the ability to make their own decisions about what happens during labour and delivery. In contrast, hospital birth respondents placed a relatively high value on access to an epidural for pain relief and not needing to be transferred to another location during labour if a problem arose. The results of the study suggest that women have clearly defined preferences for characteristics associated with the process of intrapartum care that would be unlikely to be detected by traditional benefit measures used in health economics. This finding is important where policy issues relating to aspects of maternity care service delivery are being considered.

Delivery Rooms↗

PubMed2000

Public preferences for the allocation of donor liver grafts for transplantation.

To investigate the nature of public preferences in the allocation of donor liver grafts for transplantation a social conjoint analysis (CA) technique was developed for a questionnaire survey. A convenience sample of academic and non-academic employees of a British University were invited to participate in the survey. Respondents were presented with eight choice situations in which they were asked to allocate 100 donor liver grafts between two groups of 100 individuals in urgent need of a transplant. The groups of individuals differed in terms of the length of time spent waiting, the life years gained following transplantation, age, personal responsibility for their illness and whether they were primary or re-transplant candidates. Only two respondents (0.7%) consistently chose to give all of the donor organs to the group of individuals with the highest expected length of survival whilst seven respondents (2%) exhibited strict egalitarian preferences, allocating equal numbers of donor organs to both groups irrespective of their characteristics. The vast majority of respondents indicated that they would be prepared to sacrifice some gain in the efficiency of the transplantation programme for an increase in equity or fairness in the allocation of donor livers. Using social CA it was possible to establish the relative weight attached to each characteristic in determining individual's allocation decisions.

Health Care Rationing↗

PubMed2000

The use of conjoint analysis to elicit willingness-to-pay values. Proceed with caution?

There is a growing interest in the potential use of conjoint analysis (CA) as a tool for estimating patient preferences within the economic evaluation of healthcare technologies. It has been suggested that where cost is included as one of the attributes within the exercise, CA can be used to estimate willingness to pay (WTP) for healthcare interventions indirectly within the framework of cost-benefit analysis. While recognizing the potential advantages of CA as a technique for the assessment of benefits in health care, this paper recommends several avenues of investigation that need to be carefully explored before an informed judgment can be made as to the validity of eliciting WTP values using the CA methodology. It is argued that much can be learned from the use of qualitative research techniques in examining individuals' understanding and interpretation of CA questions where cost is included as an attribute in the exercise. Additionally, further research is required in defining techniques for establishing the most appropriate levels for the cost attribute in a CA exercise and in determining the sensitivity of WTP estimates to the levels that are chosen for the cost attribute.

Costs and Cost Analysis↗

PubMed2000

Economic issues in the prevention of vertical transmission of HIV.

In the absence of interventions, 20% of infants born to women infected with HIV acquire infection from their mother at or before delivery. A further 15% are infected through breast feeding. Prenatal testing for HIV allows infected women to be reliably identified so that they can receive antiretroviral therapy and, in countries with safe water supplies, be advised not to breast feed. These and other interventions can reduce the risk of transmission to 5% or less. Economic evaluations of prenatal testing for HIV are reviewed and compared in this article, and future research priorities outlined. These studies set the costs of testing and intervention against the averted lifetime costs of paediatric infection, and generate estimates of the HIV prevalence threshold above which there would be a net cost saving, or calculate the cost per life-year saved given a particular prevalence. In the developed world, prenatal testing has been adopted in many countries, and recent economic analyses broadly support this. Future research is likely to focus on the incremental benefits of different antiretroviral regimens in lowering transmission rates still further, with or without elective caesarean section, and the possibility that some may lead to adverse effects in uninfected infants exposed to them in utero. Some earlier assessments in resource-poor settings concluded that prenatal testing was unaffordable or of doubtful cost effectiveness. This negative conclusion appears to be the result of very low estimates of the lifetime costs of paediatric HIV infection, together with developed world conceptions of pre-test counselling. The demonstration that nevirapine reduces transmission risk at a low cost has transformed the outlook, and there is hope that antiretrovirals can act prophylactically to prevent infection of the breast-fed child. However, to achieve a sustained reduction in vertical transmission there may be a need to evaluate the need for a strengthened infrastructure to deliver prenatal HIV testing and treatment, as well as programmes to reduce HIV incidence in adults.

HIV Infections↗

PubMed1999

Cost effectiveness analysis of antenatal HIV screening in United Kingdom.

OBJECTIVE: To assess the cost effectiveness of universal antenatal HIV screening compared with selective screening in the United Kingdom. DESIGN: Incremental cost effectiveness analysis relating additional costs of screening to life years gained. Maternal and paediatric costs and life years were combined. SETTING: United Kingdom. MAIN OUTCOME MEASURES: Number of districts for which universal screening would be cost effective compared with selective screening under various conditions. RESULTS: On base case assumptions, a new diagnosis of a pregnant woman with HIV results in a gain of 6.392 life years and additional expenditure of 14 833 pounds. If decision makers are prepared to pay up to 10 000 pounds an additional life year, this would imply a net benefit of 49 090 pounds (range 12 300 pounds- 59 000 pounds), which would be available to detect each additional infected woman in an antenatal screening programme. In London, universal antenatal screening would be cost effective compared with a selective screening under any reasonable assumptions about screening costs. Outside London, universal screening with uptake above 90% would be cost effective with a 0.60 pounds HIV antibody test cost and up to 3.5 minutes for pretest discussion. Cost effectiveness of universal testing is lower if selective testing can achieve high uptake among those at higher risk. A universal strategy with only 50% uptake may not be less cost effective in low prevalence districts and may cost more and be less effective than a well run selective strategy. CONCLUSIONS: Universal screening with pretest discussion should be adopted throughout the United Kingdom as part of routine antenatal care as long as test costs can be kept low and uptake high.

Anti-HIV Agents↗

PubMed1999

Psychiatric training for family doctors: what do GP registrars want and can a brief course provide this?

CONTEXT: About 40% of British General Practitioners (GPs) train formally in a psychiatric post as part of their general practice training, but such training may not fully meet the needs of future GPs. A specific course in psychiatry for family doctors has run in Manchester for more than a decade. METHOD: Semi-structured interviews conducted with GP registrars before attending the Manchester course in psychiatry with questionnaire follow-up afterwards to ascertain (a) the training 'wants' of GP registrars and (b) whether the course was providing them. RESULTS: GP registrars most frequently wanted training in communication skills, how to access the resources that are available to GPs, the detection of psychiatric illness, drug treatment and the management of aggression. The course was successful in satisfying the first three but failed in the last two. There was trend for those who attended Manchester Medical School, which scored significantly higher on number of topics covered at undergraduate level, to perceive a greater need for training than those who attended other medical schools. However, there was no evidence to link self-perception of greater need with having already worked in general practice during postgraduate training. CONCLUSIONS: More attention needs to be paid to how to address the specific mental health skills training requirements of GP registrars both within the attachment in psychiatry and during the practice year. Preliminary research is required to devise teaching packages before they are entirely satisfactory for GP education.

Education, Medical, Continuing↗