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Biomedical subjects

Joanna Coast

Publications and source records attributed to Joanna Coast.

At least 19 recordsLinked to original sources
PubMed2006

Best--worst scaling: What it can do for health care research and how to do it.

Statements like "quality of care is more highly valued than waiting time" can neither be supported nor refuted by comparisons of utility parameters from a traditional discrete choice experiment (DCE). Best--worst scaling can overcome this problem because it asks respondents to perform a different choice task. However, whilst the nature of the best--worst task is generally understood, there are a number of issues relating to the design and analysis of a best--worst choice experiment that require further exposition. This paper illustrates how to aggregate and analyse such data and using a quality of life pilot study demonstrates how richer insights can be drawn by the use of best--worst tasks.

Consumer Behavior↗
PubMed2006

A macroeconomic approach to evaluating policies to contain antimicrobial resistance: a case study of methicillin-resistant Staphylococcus aureus (MRSA).

BACKGROUND: Antimicrobial resistance (AMR) is, at least in part, associated with high antimicrobial usage and causes increased morbidity, mortality and healthcare costs. However, policies to contain AMR focus on 'micro' interventions - typically in one institution (usually a hospital). Furthermore, in evaluating these interventions, economists tend to concentrate on the economic impact to the healthcare sector alone, which may give an incorrect estimation of the social costs and benefits of a disease or intervention. METHODS: This study outlines and illustrates a macroeconomic approach to tackling AMR through the evaluation of three 'macro' policies: regulation, permits and taxes/charges. In addition to effects on the healthcare sector, the effect of AMR (and these three policies to contain it) on labour productivity, GDP, household income, government transfers, tax revenues, unemployment, inflation and social services are estimated for the UK using the specific context of methicillin-resistant Staphylococcus aureus (MRSA). RESULTS: AMR is likely to have a far greater impact on the national economy than would be estimated by concentrating on the healthcare sector alone. CONCLUSION: The permit system appears to offer the most efficient 'solution' to optimising antimicrobial consumption and, hence, reducing the development of resistance.

Anti-Infective Agents↗
PubMed2005

Economic evaluation of a general practitioner with special interests led dermatology service in primary care.

OBJECTIVE: To carry out an economic evaluation of a general practitioner with special interest service for non-urgent skin problems compared with hospital outpatient care. DESIGN: Cost effectiveness analysis and cost consequences analysis alongside a randomised controlled trial. SETTING: General practitioner with special interest dermatology service covering 29 general practices in Bristol. PARTICIPANTS: Adults referred to a hospital dermatology clinic who were potentially suitable for management by a general practitioner with special interest. INTERVENTIONS: Participants were randomised 2:1 to receive either care by general practitioner with special interest service or usual hospital outpatient care. MAIN OUTCOME MEASURES: Costs to NHS, patients, and companions, and costs of lost production. Cost effectiveness, using the two primary outcomes of dermatology life quality index scores and improved patient perceived access, was assessed by incremental cost effectiveness ratios and cost effectiveness acceptability curves. Cost consequences are presented in relation to all costs and both primary and secondary outcomes from the trial. RESULTS: Costs to the NHS for patients attending the general practitioner with special interest service were 208 pounds sterling (361 dollars; 308 euro) compared with 118 pounds sterling for hospital outpatient care. Based on analysis with imputation of missing data, costs to patients and companions were 48 pounds sterling and 51 pounds sterling, respectively; costs of lost production were 27 pounds sterling and 34 pounds sterling, respectively. The incremental cost effectiveness ratios for general practitioner with special interest care over outpatient care were 540 pounds sterling per one point gain in the dermatology life quality index and 66 pounds sterling per 10 point change in the access scale. CONCLUSIONS: The general practitioner with special interest service for dermatology is more costly than hospital outpatient care, but this additional cost needs to be weighed against improved access and broadly similar health outcomes.

Ambulatory Care↗
PubMed2005

Evaluation of a general practitioner with special interest service for dermatology: randomised controlled trial.

OBJECTIVE: To assess the effectiveness, accessibility, and acceptability of a general practitioner with special interest service for skin problems compared with a hospital dermatology clinic. DESIGN: Randomised controlled trial. SETTING: General practitioner with special interest dermatology service and hospital dermatology clinic. PARTICIPANTS: Adults referred to a hospital dermatology clinic and assessed by a consultant or the general practitioner with special interest service,. Suitable patients had non-urgent skin problems and had been identified from the referral letter as suitable for management by a general practitioner with special interest. INTERVENTIONS: Participants were randomised in 2:1 ratio to receive management by a general practitioner with special interest or usual hospital outpatient care. MAIN OUTCOME MEASURES: Primary outcomes were disease related quality of life (dermatology life quality index) and improvement in patients' perception of access to services, assessed nine months after randomisation. Secondary outcomes were patient satisfaction, preference for site of care, proportion of failed appointments, and waiting times to first appointment. RESULTS: 49% of the participants were judged suitable for care by the general practitioner with special interest service. Of 768 patients eligible, 556 (72.4%) were randomised (354 to general practitioner with special interest, 202 to hospital outpatient care). After nine months, 422 (76%) were followed up. No noticeable differences were found between the groups in clinical outcome (median dermatology life quality index score = 1 both arms, ratio of geometric means 0.99, 95% confidence interval 0.85 to 1.15). The general practitioner with special interest service was more accessible (difference between means on access scale 14, 11 to 19) and waited a mean of 40 (35 to 46) days less. Patients expressed slightly greater satisfaction with consultations with a general practitioner with special interest (difference in mean satisfaction score 4, 1 to 7), and at baseline and after nine months 61% said they preferred care at the service. CONCLUSIONS: The general practitioner with special interest service for dermatology was more accessible and preferred by patients than hospital outpatient care, achieving similar clinical outcomes. Trial registration ISRCTN31962758.

Adolescent↗
PubMed2005

Developing attributes for a generic quality of life measure for older people: preferences or capabilities?

Current UK policy with respect to the provision of health and social care for older people suggests that greater integration is required. Economists' attempts to assist resource allocation decisions, however, are very health focused, with concentration on the use of health-related quality of life measures. This paper reports an attempt to determine attributes for a new index clearly focusing on quality of life for older people rather than health or other influences on quality of life. In-depth interviews were conducted with 40 purposively selected informants aged 65 and over in private households to explore their views about what is important to them in terms of quality of life. Data were analysed using Framework qualitative analysis. Initial discussions tended to concentrate upon factors influencing quality of life including activities, relationships, health, wealth and surroundings. Further probing and analysis suggested five conceptual attributes: attachment, role, enjoyment, security and control. The data also suggested that the quality of informants' lives was limited by the loss of ability to pursue these attributes. So, for example, it is not poor health in itself, which reduces quality of life, but the influence of that poor health upon each informant's ability to, say, be independent, that is important. Amartya Sen's work on functioning and capability is particularly pertinent here. Using this work, it is possible to interpret the five conceptual attributes as a set of functionings-important for older people in the UK in the 21st century-but noting that it is the capacity to achieve these functionings that appears to be of importance. This suggests that further development of this measure should focus on an index of capability rather than preference-based utility.

Activities of Daily Living↗
PubMed2005

A cost-consequences analysis of minor injuries telemedicine.

A cost-consequences analysis of minor injuries telemedicine was performed alongside a randomized controlled trial in a UK peripheral emergency department. The main outcome measures were safety and clinical effectiveness at seven days after presentation. Costs to the National Health Service (NHS) and patients and their families, for 253 patients, were estimated for seven days following randomization. The mean cost to the NHS for the telemedicine patients was 78.61 pounds and for those assessed routinely was 39.15 pounds. For costs incurred by patients and their families the respective figures were 58.24 pounds and 43.95 pounds. Sensitivity analysis showed the initial results to be robust. Telemedicine was a more expensive option for providing minor injuries care in a general-practitioner-supported peripheral emergency department, while consequences did not vary greatly between the different options.

Emergency Service, Hospital↗
PubMed2005

Quality-adjusted life-years lack quality in pediatric care: a critical review of published cost-utility studies in child health.

OBJECTIVES: Cost-utility analysis in which health benefits are quantified in terms of quality-adjusted life-years (QALYs) has now become the standard type of cost-effectiveness analysis. These studies are potentially influential in determining the extent of funding for particular pediatric interventions, and so their methodologic quality is extremely important. The objective of this study was twofold: first, to critically appraise published cost-utility analyses of interventions in child and adolescent health care in terms of the methods used to derive QALYs and, second, to discuss unresolved methodologic issues that are pertinent to the measurement of QALYs in pediatric populations. METHODS: A comprehensive search using computerized databases (including Medline, Embase, Econlit, and databases specific to economic evaluation), Web searches, and citation tracking was undertaken to identify cost-utility studies of interventions that were aimed at those who were younger than 16 years and published before April 2004. The methods of individual studies were compared with the recognized published guidelines of the US Panel on Cost-Effectiveness in Health and Medicine and the National Institute for Clinical Excellence in England and Wales, which recommend the use of a generic health state classification system (eg, Health Utility Index, EuroQol-5D), a choice-based valuation method (eg, standard gamble or time trade-off) and preferences of the general public in estimating QALYs. Studies therefore were categorized and evaluated according to the methods used to describe the health state, the valuation technique, and source of preferences. RESULTS: Fifty-four studies were reviewed, 34 (63%) of which were published in the past 5 years. A generic health status classification instrument was used in 22 (35%) cases; the remainder developed study-specific health state descriptions or elicited preferences directly from patients or proxies. In 3 (5%) cases, sources were unclear. Preference weights were elicited using choice-based techniques in 28 (42%) cases, either as tariffs for health status classification instruments (17 cases) or by directly valuing health state descriptions or patient health (11 cases). Preferences of the general public were used in only 23 (37%) cases. Four studies aggregated QALYs for mother/child or parents/child pairs without giving any theoretical justification. Although there was an increasing tendency for studies to use generic health status classification instruments, choice-based methods, and preferences of the general public, the majority of studies still did not adhere to these standard recommendations even in the period between January 2000 and March 2004. Despite increasing standardization in the methods advocated for economic evaluation over the past 10 years, there remains extensive variation in the actual methods used by researchers to calculate QALYs for children and adolescents. It is unclear whether these results suggest poor practice or a set of positive (or reactive) choices made by analysts in a methodologically uncertain area in which specific guidance is lacking regarding how to address the complexities of pediatric outcomes within the QALY framework. Many aspects of QALY measurement in children are not yet fully developed. In particular, there is (1) a lack of appropriate health state classification instruments that take account of the dynamics of child development, (2) a lack of health state classification instruments for use in children and infants who are younger than 5 years, and (3) the need to understand fully the role of proxies for measuring and valuing child health. Additional research efforts are also required to develop methods that account for the health benefits of parents or caregivers of the child and to consider the implications of combining different forms of utility measurement in childhood and adulthood. CONCLUSIONS: Although variations from standard recommendations may be attributable to poor practice among researchers who are either unaware of these recommendations or choose not to follow them, they could equally be the result of attempts to make research more rigorous and more defensible than it might be if the standard recommendations were followed. There are 4 potential approaches to conducting cost-utility analysis in pediatric populations: (1) the explicit development of a generic instrument designed to be applicable across both child and adult populations (likely to be difficult in practice), (2) insistence on use of a generic instrument developed for adults, (3) the use of generic instruments specifically developed for children without being concerned about comparability with interventions aimed at adults, and (4) abandoning attempts to use single outcome measures that combine mortality with quality weights. In the absence of a clear way forward, it is suggested that an expert panel be convened to debate and further consider these potential solutions and recommendations for best practice and future research. In the interim, comparisons of the relative cost-effectiveness reported as cost per QALY gained across interventions for different diseases and populations should be treated with extreme caution.

Adolescent↗
PubMed2004

Issues arising from the use of qualitative methods in health economics.

As health economists begin to embrace qualitative methodology they inevitably face a number of issues. This paper explores these, distinguishing between those associated with the conflict between quantitative and qualitative methodologies (that has already been faced in a number of other research areas) and those associated with the potential for challenges to the discipline of mainstream economics. The former include both the acceptability of the methods (because of issues such as generalisability and reflexivity) and the acceptability of presentation. The latter appear to be essentially concerned with identity within economics. The paper concludes by noting the positive aspects of conducting qualitative research in health economics: the interesting and motivating nature of the research and, particularly, the possibilities for increasing the relevance associated with economic theory in the context of health and health services.

Evaluation Studies as Topic↗
PubMed2003

Patient-reported use of health service resources compared with information from health providers.

The objectives of the present study were to examine the accuracy of older people's reports of health services resource use after discharge from acute care compared with information from healthcare providers. Paired data were obtained from health providers and a consecutive sample of hospitalised patients (aged 60 years or over) enrolled in a randomised controlled trial of hospital-at-home versus usual acute care. Retrospective reports of the use (yes/no) and number of patient hospital admissions, and community nursing, physiotherapy, health visiting and general practitioner (GP) services were obtained between baseline, and 4- and 12-week follow-ups, although the recall period varied for different resources. The comparability of paired reports was examined by using crude and chance-corrected agreement, and by testing for systematic differences in the distribution of paired responses. Out of 219 patients enrolled in the trial, 190 and 185 patients provided data at 4 (87%) and 12 weeks (84%), respectively. Crude agreement was over 72% (range = 42-93%), and chance-corrected agreement was moderate or good (kappa coefficients from 0.23 to 0.71) for 11 out of 12 comparisons. Systematic differences in the pattern of paired responses were observed for seven comparisons. Patients more often reported receiving a routine GP home visit (by 12 weeks), whilst health providers reported statistically significantly (P < 0.05) more patients admitted to hospital (12 weeks) and more admissions per person, requesting a GP home visit (12 weeks) or surgery consultation, and having district nursing (4 and 12 weeks) and physiotherapy (4 weeks only). The data indicate that patients tend to underestimate resources used compared with health providers over relatively short time frames.

Aged↗
PubMed2003

Interventions to improve access to health and social care after discharge from hospital: a systematic review.

OBJECTIVES: To determine the effectiveness and costs of interventions intended to improve access to health and social care for older patients following discharge from acute hospitals. METHOD: Systematic literature review, following NHS Centre for Reviews and Dissemination guidelines, of randomised controlled trials evaluating needs assessment methods and patient discharge co-ordinator roles. These services targeted patients aged 60 years and over and varied depending on whether or not they selected frail patients (e.g. those at risk of needing nursing home care). Outcomes assessed included: referrals to or use of health and social care (15 studies); mortality (13 studies); patients' functional health status and disability (13 studies); and patient perceptions of health (five studies), quality of life (three studies), cognitive functioning and psychological well-being (ten studies), social support (two studies) and the adequacy of services (four studies). RESULTS: Fifteen randomised controlled trials (23 papers), mainly from the USA, were identified. The interventions provided and patient groups targeted by these services were heterogeneous. There was, however, some evidence that services combining needs assessment, discharge planning and a method for facilitating the implementation of these plans were more effective than services that do not include the latter action. CONCLUSIONS: The assessment of need may be insufficient in itself for the adequate provision of post-discharge care. Needs assessment should be combined with a service that facilitates the implementation of care plans.

Aftercare↗
PubMed2003

Antimicrobial resistance: cost and containment.

There is growing evidence that antimicrobial resistance causes serious consequences for individuals as well as leading to increased healthcare costs. The containment of resistance is therefore a policy problem which will impact on all health systems in the next few years. Unfortunately, there is, as yet, no definitive evidence suggesting that particular control measures are successful in containing either the emergence or transmission of antimicrobial resistance. Furthermore, few studies contain information about costs and even where there is such information it is generally inadequate because of the narrow perspectives from which analyses are conducted. In part, this is due to methodological problems associated with the inclusion of cost data: measuring and valuing what are often intangible costs; identifying costs associated with organizational change; and accounting for interaction between costs at levels from the individual to the international. Good quality research, including both economic evaluation and comprehensive economic modelling, is required to determine the most cost-effective combination of strategies to pursue in combating resistance, and to find ways around these methodological difficulties.

Animals↗
PubMed2002

Superbugs II: how should economic evaluation be conducted for interventions which aim to contain antimicrobial resistance?

To date, there has been little examination of the problems associated with conducting economic evaluation for interventions designed to contain antimicrobial resistance. There are two quite different types of intervention aimed at containing antimicrobial resistance: interventions which are designed to avoid the emergence of resistant organisms; and interventions that are designed to avoid the transmission of resistance organisms. Four aspects of economic evaluation where the ease of assessment might be expected to differ across evaluations for these different types of intervention are examined: problems associated with the identification of diffuse impacts, problems associated with comparing current and future impacts, problems associated with uncertainty, and problems associated with difficulties in measurement and valuation. The paper suggests that it may be much easier to conduct rigorous economic evaluations for interventions designed to avoid transmission of resistance, than for those intended to avoid emergence. Unfortunately, the transmission policies, which are likely to be the easiest to evaluate, are not likely to produce an optimal long-term outcome given the apparent irreversibility of much resistance and the potentially severe harms which could be imposed as a result. Given the desirability of avoiding a scenario where, in the evidence-based medicine culture, the most rigorously evaluated policies are followed even though they may be less important, there is the need to consider carefully what, and how, economic evaluation should be conducted in the area of antimicrobial resistance. It is suggested that research should focus on the use of modelling as a means of evaluating optimal policy responses and on trying to resolve some of the difficulties associated with measurement and valuation.

Anti-Infective Agents↗
PubMed2002

Transurethral prostate resection, noncontact laser therapy or conservative management in men with symptoms of benign prostatic enlargement? An economic evaluation.

PURPOSE: We evaluated the cost-effectiveness of noncontact laser therapy compared with transurethral prostate resection and conservative treatment in men with symptoms associated with benign prostatic enlargement. MATERIALS AND METHODS: A total of 340 men with uncomplicated lower urinary tract symptoms participated in a large multicenter pragmatic randomized trial called the CLasP (Conservative management, Laser therapy, transurethral resection of the Prostate) study. Costs to the United Kingdom National Health Service and patients were determined from the time of randomization to the 7.5-month followup. Incremental cost-effectiveness ratios using conservative management as the base case were calculated for certain trial outcomes, including International Prostate Symptom Score (I-PSS), I-PSS quality of life score, maximum urinary flow, post-void residual urine volume, quality adjusted life-years and a composite measure of success based on I-PSS and maximum urinary flow. One-way sensitivity analysis of the basic costs and incremental cost-effectiveness ratios were done from the NHS viewpoint. RESULTS: Mean costs per patient were greatest for noncontact laser therapy and least for conservative management. The incremental cost-effectiveness ratios showed that transurethral prostate resection was more cost-effective than noncontact laser treatment for all primary trial outcomes. The incremental cost-effectiveness ratios of transurethral prostate resection compared with conservative management were pound 81 per unit decrease in the I-PSS score and pound 1,338 per additional successful case per 100 patients. Sensitivity analysis showed that the initial results were robust. CONCLUSIONS: Noncontact laser was the mostly costly treatment option. Transurethral prostate resection was more cost-effective than noncontact laser therapy in terms of symptomatic improvement. In men wishing to delay treatment conservative treatment appears to provide a cost-effective alternative in the short term.

Adult↗
PubMed2002

'The public is too subjective': public involvement at different levels of health-care decision making.

There are a number of impulses towards public participation in health care decision making including instrumentalist, communitarian, educative and expressive impulses and the desire for increased accountability. There has, however, been little research looking systematically at the public's preferences for being involved in particular types of rationing decisions, nor indeed, has there been a critical examination of the degree of involvement desired by the public. The research reported here uses findings from focus groups and in-depth interviews to explore these questions. Eight focus groups were conducted with a total of 57 informants, four amongst randomly selected members of the public and four with informants from health and non-health related organisations. Nineteen interviews were conducted to allow the elaboration of focus group comments, to probe views more deeply and to pursue emerging themes. The findings show variations in the willingness of members of the public to be involved in health care decisions and consistency across the different forms of the public as represented by the focus groups with randomly selected citizens and pre-existing organisations. There was a strong desire in all the groups for the public to be involved both at the system and programme levels, with much less willingness to be involved at the individual level. At the system and programme levels informants generally favoured consultation, without responsibility for decisions, but with the guarantee that their contribution would be heard and that decisions taken following consultation would be explained. At the patient level informants felt that the public should participate only by setting criteria for deciding between potential beneficiaries of treatment. The public has much to contribute, particularly at the system and programme levels, to supplement the inputs of health care professionals.

Attitude to Health↗
PubMed2002

"If there were a war tomorrow, we'd find the money": contrasting perspectives on the rationing of health care.

In spite of the substantial academic effort being devoted to the subject of health care rationing, there is little clarity about the views of those working in health care who have to implement rationing nor about the views of citizens who are (potentially) affected by the rationing of care. This paper reports the findings of a study conducted using focus groups and semi-structured interviews to explore and compare beliefs about rationing among citizens and those with a role in the health service (service informants) within the context of health care provision in the UK. Citizen and service informants both identified external pressures on the resources available for health care including technological improvement, the ageing population and increasing public expectations. Citizens, however, also identified such factors as the political choice to provide insufficient funds to the health service and the wasteful use of resources that are available. The predominant view was that these latter factors were amenable to change and thus that there are alternatives to the rationing of care. Some citizens accepted that some health care rationing might be necessary. Service informants, on the other hand, were cynical about prospects of increased funding and viewed further reductions in management as untenable. For them, rationing was an inevitability to be managed. A number of these informants felt that rationing should become more explicit, suggesting that openness made rationing both more democratic and more practical. Others, however, believed that explicit rationing would have a number of uncomfortable implications. The paper concludes by suggesting that if rationing is to become more explicit, its inevitability, as perceived by those working within health care, will have to be communicated to citizens.

Attitude of Health Personnel↗
PubMed2002

Strategies to contain the emergence of antimicrobial resistance: a systematic review of effectiveness and cost-effectiveness.

OBJECTIVES: To conduct a systematic review of the literature to describe and critically appraise studies reporting on the cost and/or effectiveness of interventions proposed to control the emergence of antimicrobial resistance (AMR). METHODS: The search for relevant studies encompassed consultation with world experts in AMR, and electronic bibliographic database search of: Medline (1960-2000); ISI (1981-2000); EMBASE (1988-2000); Grey Literature (1999-2000); Database of Reviews of Effectiveness (DARE) and the NHS Health Economic Evaluation Database (HEED) at York University's Centre for Reviews and Dissemination (CRD) (numerous years); OPAC (1975-2000); and the Cochrane Library Online (1990-2000). Only studies that concerned the effectiveness or cost-effectiveness of measures specifically designed to contain the emergence of AMR were reviewed. Standardised data extraction sheets, based on existing checklists for effectiveness and cost-effectiveness, were used to assess the validity of each study using the 'risk of bias criteria' suggested in the Cochrane Handbook. Only studies categorised as being at low or moderate risk of bias were reported fully. The reliability of the data review process was monitored by comparison of several, random, independent assessments by all authors. The mix of study methods (i.e. including studies based on non-randomised controlled trials) meant that formal meta-analysis was not possible, and thus a qualitative review was performed. RESULTS: In total, 43 studies were reviewed, with 21 classed as being at moderate or low risk of bias and therefore reported in the paper. These studies covered policies on: restricting the use of antimicrobials (five studies, suggesting that restriction policies can alter prescriber behaviour, although with limited evidence of subsequent effect on AMR); prescriber education, feedback and use of guidelines (six studies, with no clear conclusion); combination therapies (seven studies, showing the potential to lower drug-specific resistance, although for an indeterminate time period); vaccination (three studies showing cost/effectiveness). Most of these studies were: from the developed world, principally the USA; hospital-based, with few community level interventions; and concerned with effectiveness, not cost-effectiveness. CONCLUSIONS: Overall, there is an absence of good evidence concerning what is effective, and especially cost-effective, in reducing the emergence of AMR. However, in addition to more research concerning these forms of intervention, the paper highlights four specific areas for further investigation: validating intermediate or surrogate outcome measures to enable better use to be made of the literature on intermediate measures; development and evaluation of 'macro' strategies; research into specific aspects of AMR in developing countries; and empirical and methodological research concerning the economic evaluation of interventions.

Anti-Bacterial Agents↗