PubMed Health⌕ Search

Biomedical subjects

R Beech

Publications and source records attributed to R Beech.

At least 37 records · Page 2Linked to original sources
PubMed1995

Using operational research modelling to improve the provision of health services: the case of DNA technology.

Operational research (OR) analysis provides information and systems to support decision making. In health care there are examples of OR being used to support decisions surrounding both the organization of health services and the treatment of individual patients. However, its uptake is currently low in spite of the increase in potential areas of application. In practice there is a lack of awareness amongst health service staff about what OR is and how it can help. This paper addresses this issue by exposing the contribution that OR made to a programme of research relating to DNA technology. Examples are given of the way it was used to provide information on the costs and outcomes of services and the ways these evolve over time. These examples demonstrate the way OR methods increase the understanding of both analysts and service providers about a problem area. This helps ensure that appropriate and valid approaches to tackling problem areas are developed. When developing these approaches, the problem orientated philosophy of OR means analysts are willing to use a range of methodologies, some originating in OR and some in other disciplines. The broad focus of OR also means that its findings enhance those provided by other disciplines which might seem to be competitors. The conclusion of the paper is that OR has a crucial role to play in the improvement of health services.

DNA↗
PubMed1995

Stroke care in Europe. Can we learn lessons from the different ways stroke is managed in different countries?

Stroke is a major health care problem in the European Union and consumes significant resources. The mortality rates from stroke and treatment strategies vary significantly between member states. Only by comparison between centres in different member states with differing health care delivery can the effect of these varying approaches to the management of stroke on outcome be assessed. Conducting a study on a European wide basis in centres which are known to differ in terms of treatment strategies and outcomes allows an immediate analysis of the effectiveness, resource requirements and cost of different methods of managing stroke patients. This paper addresses the current burden of stroke and strategies for its management. An outline of a European Union project, assessing how stroke is managed in different countries, is provided with the aim of indicating a strategy for discovering and promoting more cost-effective services for stroke care in the future.

Aged↗
PubMed1995

Understanding variations in lengths of stay between hospitals for fractured neck of femur patients and the potential consequences of reduced stay targets.

BACKGROUND: Economic incentives exist to scrutinize length of stay variations between hospitals. However, the reasons for variations can be complex, and without knowing these the feasibility of shorter stay targets, and their implications for patient outcome, are unclear. METHODS: This research compared care received by patients admitted for fractured neck of femur at an inner-city university teaching hospital, an inner-city associated teaching hospital and an associated teaching hospital in an urban setting. Multiple regression and descriptive analysis were used to examine how in-patient acute stay was affected by the severity of cases on admission and the supply of beds beyond the acute setting. Data on patient outcome were mortality up to three months post fracture and functional ability at in-patient discharge and three months post fracture. RESULTS: A total of 492 patients were recruited. Patient outcomes at three months were similar at the hospitals. Multiple regression revealed significant differences between the patient stay of the inner-city teaching hospital and the urban associated teaching hospital. A difference in stay of around 14 days was demonstrated, with the urban hospital having the shorter stay. These differences were linked it to having a greater supply of non-acute beds. CONCLUSION: Significant differences in patient stay between hospitals can be due to factors beyond the direct control of the acute unit. Economic incentives may mean that purchasers and providers ignore a full analysis of these factors and set length of stay targets which are not feasible in the short term. This could reduce the quality and impair the outcome of patient care.

Activities of Daily Living↗
PubMed1995

Variations in the incidence, management and outcome of stroke in residents under the age of 75 in two health districts of southern England.

BACKGROUND: The aim of the study was to determine the incidence, outcome and health service resources consumed by stroke care in defined populations. METHODS: Patients under the age of 75 experiencing their first stroke between August 1989 and July 1991 were assessed at the onset, and at three and 12 months after their stroke. The settings were West Lambeth (WL) and Tunbridge Wells (TW) health authorities in southern England. The main outcome measures used were: age- and sex-specific incidence rates, hospital admission rates, length of stay and use of rehabilitation services. Functional disability was assessed using the Barthel scale. RESULTS: Four hundred and fifty-six strokes were registered. The annual incidence rates/1000 population aged under 75 years old [with 95% confidence interval (CI)] were 0.77 (0.67-0.87) in WL and 0.66 (0.58-0.75) in TW. The age- and sex-standardized incidence ratios were significantly higher in WL (126; 95% CI 110-144) than in TW (84%; 95% CI 74-95) (p < 0.001). There were independent associations of incidence with age group (p < 0.001), sex (p < 0.001) and ethnic group (p < 0.001). One year case-fatality was 36% (80/225). At one year, 11% (14) of surviving patients were moderately to severely disabled and 23% (28) mildly disabled. Seventy-one percent (326) of patients were admitted to hospital and the average health service cost per case was pound 3800 in WL and pound 2650 in TW, 93% of the cost being for in-patient care. CONCLUSION: The study has demonstrated a significantly increased incidence of stroke in an inner-city district compared with a district in rural southern England. It has also established ethnic group as a significant independent risk factor for stroke in the United Kingdom. The cost of care to the health services is considerable, and largely reflects nursing costs in hospital rather than effective treatment packages for stroke.

Adult↗
PubMed1995

Outcome following fractured neck of femur--variation in acute hospital care or case mix?

BACKGROUND: This study examined the quality of care given to patients admitted to hospital with a fractured neck of femur by assessing the link between outcome, case severity and resource use. Fractured neck of femur was chosen for this study as it is a common condition amongst elderly people which causes considerable morbidity and mortality, uses a high proportion of acute hospital resources and is a condition where virtually all new cases will come under the care of the hospital service. METHODS: Three hospitals which had different case fatality rates and costs were included in the study. These were an inner-city teaching hospital (Hospital 1), an inner-city associated teaching hospital (Hospital 2) and an associated teaching hospital in an urban location (Hospital 3). Patients were recruited for this study over a 12-month period. Details on case severity and basic demographic date were collected on admission, and information on the process of care was collected during the hospital stay. Four outcome measures were addressed: activities of daily living (ADL) before discharge and at three months post-fracture; mortality up to 12 months post-fracture; complications occurring after admission to hospital; and destination on discharge. RESULTS: A total of 492 patients were recruited into the study, with a male to female ratio of 1:4 and an age range of 60-101 years. Patients admitted to the three hospitals showed no difference with respect to the presence of co-morbidities, medication, pre-fracture ADL, mental state, age and sex. There were some differences observed in pre-fractured place of residence. Hospital 1 had the highest proportion of patients admitted from sheltered housing and other hospital. Hospital 2 the highest proportion from residential homes, and Hospital 3 the highest proportion admitted from their own homes. Hospital 3 discharged patients at an earlier stage of recovery in that a higher proportion were discharged with a poor ADL index. This hospital also had more orthopaedic complications but fewer medical complications; however, the outcome in terms of ADL at three months post-fracture and mortality at 12 months was similar in all three hospitals. The severity variables which predicted poor outcome were co-morbidities, impaired mental state, impaired ADL pre-fracture, increasing age and an extracapsular fracture. After controlling for severity variables, the resource variables had not further impact on mortality, either in hospital or within one year. An epidural anaesthetic was related to a poor ADL at three months and more orthopaedic complications but fewer medical complications. There was also a hospital effect in that Hospital 3, which performed the most epidurals, had the highest proportion of orthopaedic complications but the lowest proportion of medical complications. When the operating surgeon was a consultant, there were more orthopaedic complications, but this was not related to these patients having a worse case severity on admission. However, among the cases operated on by consultants, there were no hospital deaths. No other resource variables were related to ADL at three months, or orthopaedic or medical complications. CONCLUSIONS: The results show that a poor outcome following a fractured neck of femur was related to increased case severity at the time of fracture. The resource variables had very little impact on the outcome.

Activities of Daily Living↗
PubMed1994

The resource implications and service outcomes of genetic services in the context of DNA technology.

The use of DNA technology has transformed genetic counselling services for single gene disorders. For conditions such as Duchenne muscular dystrophy and cystic fibrosis, both of which cause severe morbidity and premature death, DNA tests mean that individuals can be told with greater certainty whether they are carriers of a genetic trait and of the likelihood of their having a child affected by the disorder. This paper presents the findings of an evaluation of the resource implications and service outcomes of genetic services in the context of DNA technology (DNA services). Results are based on data collected over a 4-year period from three large genetics centres throughout the United Kingdom. Our conclusions are that for the conditions for which they are commonly used, and as a regionally based service, DNA services are effective and relatively inexpensive. For severe conditions, and for neurological disorders, although tests will not alter family size plans the demand for tests during pregnancy will be high and the results will have a significant impact on individuals' decisions regarding the continuation of their pregnancies. For conditions of variable severity, those that start late in life or are amenable to treatment, the demand for tests is likely to be low. In comparison with the general population we found a greater existence of psychological side effects amongst counsellees. These effects were linked to individuals having a close relative, usually a child, already affected by a disorder rather than being a consequence of the genetic counselling process.

Adult↗
PubMed1994

The influence of genetic counselling in the era of DNA testing on knowledge, reproductive intentions and psychological wellbeing.

Subjects of reproductive age at risk of having an affected child with a severe single gene disorder such as Duchenne muscular dystrophy (DMD) or cystic fibrosis (CF) were surveyed to ascertain: their views on genetic counselling and antenatal testing; their knowledge of their risk of having an affected child; and their psychological wellbeing. Questionnaires were posted to 209 individuals at 130 addresses; a 65% response rate was achieved. The majority of those surveyed were under 40 years of age (91%), half of them had received genetic counselling only once and for 47% the first encounter was after the diagnosis of their affected child. Most patients expressed their intention to use prenatal testing. However, less than 50% of those counselled knew their risk of having an affected child. Knowledge of risk was associated with the type of disease in the family (p < 0.001) (inheritance of DMD was poorly understood by relevant subjects) and was positively associated with the participant's level of education (p < 0.05). We did not detect a significant association between the number of intended children and the risk of having an affected child. In terms of family relations, genetic counselling appears to be beneficial for the nuclear family, the couple and their children, but some counselees reported a deterioration in relations with other relatives. The results indicate that couples at risk of having a child with a severe genetic disorder value the counselling provided, but many of them do not remember important facts in relation to their risk status.

Adolescent↗
PubMed1993

Purchasing services for end stage renal failure: the potential and limitations of existing information sources.

Renal replacement therapy services already consume considerable health service resources and, as patient stock levels rise and unmet need continues to be identified, the pressure to spend more on renal services will increase. Purchasers of services must decide how to respond to these pressures, and a clear assessment of need and the effectiveness and efficiency of services are key issues when contracts are being developed for such services. This paper reports an examination of the quality and potential of information currently available from routine data sources to support the contracting process. The results expose gaps in current knowledge and identify areas for future research. Locally, purchasers should consider surveying their population to identify the incidence of renal disease, including the reasons for any unmet need. Nationally, research is required to investigate the following: the relationship between ethnicity and the development of renal disease; the criteria for allocating patients to the alternative treatment modalities; and the treatments in terms of their costs and cost-effectiveness.

Age Factors↗
PubMed1993

The process of evaluation of a new technology: genetic services and the introduction of DNA probes.

This paper gives a summary of the main results and recommendations, contained in reports for the Department of Health, of an evaluation of the introduction of DNA probes in the service activity of clinical genetics. The reports analysed cost and benefits of this technology, the potential demand for its use, the characteristics of the families referred to the service in terms of social and geographical distribution, the relative impact of DNA probes on the work-load of services in comparison with other activities, and the communication skills required by geneticists in relation to patients and other colleagues. However, the major element of this paper is the discussion of issues related to the process of evaluation. There has recently been discussion about ways to improve dissemination of results of health services research. We discuss here the major barriers that public health physicians and health service researchers need to address when playing the role of independent evaluators of services or new technologies. During the course of the evaluation of DNA testing, major changes occurred in the NHS. The evaluator will have to consider not only the costs and effectiveness of the new technology, but also how the findings are interpreted by the providers within the constraints of the new organizational structure.

Clinical Competence↗
PubMed1992

Constraints on innovatory practice: the case of day surgery in the NHS.

Rates of adoption of new technology or innovatory practices depend upon their inherent managerial and clinical incentives. Rates will be highest where these incentives coincide and lowest where both are weak. Within this framework we examine the current low rate of adoption of day surgery in the National Health Service (NHS) of the United Kingdom (UK). We assess the current managerial incentives for the introduction of day surgery in terms of its potential either to achieve financial savings or to allow expansions in overall hospital caseload. These are both shown to have been low within the context of the traditional method of funding health care in the NHS. Clinical attitudes and their perceptions of the barriers to day surgery are examined based on data from a survey of 240 consultant surgeons. A high proportion of surgeons regard day surgery as clinically acceptable for a wide range of procedures, but the limited clinical appeal of day surgery procedures and the lack of day facilities have further limited its adoption. These findings are considered in the context of the revised methods of funding hospital services in NHS, introduced from April 1991. Priorities may change with managerial incentives playing a greater role in the introduction of new technologies and innovatory practices.

Ambulatory Surgical Procedures↗
PubMed1992

A methodology for simulating the impact of DNA-probe services on the outcomes of pregnancies.

For certain single-gene disorders, DNA probes allow individuals to make more informed decisions about family size and the outcomes of pregnancies. They may also have important psychological effects. We present a method of assessing their impact on the outcomes of pregnancy. We conclude that the traditional approach, which focuses solely on the potential of prenatal diagnostic services to reduce affected births, is limited. It neglects the potential of such services to promote an increase in unaffected births by reducing the number of unnecessary terminations.

DNA Probes↗
PubMed1992

DNA probe technology: implications for service planning in Britain.

For certain genetic conditions DNA testing identifies carriers and determines the risk status of foetuses, thus helping parents to make more informed prenatal decisions. Data, collected from three genetic centres in England and Wales from August 1986 to July 1990, are used to describe trends in demand for DNA testing, the impact of DNA tests on carrier risk assessment, and the use of DNA tests in relation to pregnancy outcome. Altogether the data include 23,388 subjects and 681 pregnancies in 8738 families divided into five cohorts by year of entry and referral. The most frequent gene disorders referred to the genetic centres are currently being tested or will soon be tested. For these disorders the initial high level of activity has declined and may have reached steady state. Demand for DNA services is high for cystic fibrosis and Duchenne muscular dystrophy, intermediate for Huntington's disease, and low for adult polycystic kidney disease, phenylketonuria and tuberous sclerosis. Based on these findings we suggest that demand for DNA tests will be high in serious, untreatable and slow progressing conditions with early onset; intermediate for conditions affecting intellect and neurological integrity with later onset; and low for treatable, late-onset conditions, or those for which there is evidence of heterogeneity, and variable penetrance. It would be helpful to assess the extent to which this view of demand is confirmed when the new disorders being DNA tested are considered and for the pattern of activity of DNA testing for some types of cancer. Since no DNA centre could offer a fully comprehensive testing service, it is recommended that a structure is created to audit overall activity, assist in policy formulation, and influence supraregional service organisation, in order that the spread of DNA services be planned as effectively as possible. This structure would facilitate monitoring of the evolution of contract specifications agreed by commissioners and providers on a regional basis.

Adolescent↗
PubMed1992

Surgeons' views of day surgery: is there a consensus among providers?

Managers and purchasers of health services are being encouraged to expand day surgery as a means of providing high-quality care and reducing costs per case and waiting times. This study examined general surgeons' views of day surgery with particular reference to day case inguinal hernia repair. A postal questionnaire was completed by 240 consultants (85 per cent) in four Regional Health Authorities. Only 11 per cent were regularly undertaking day case inguinal hernia repair, a further 44 per cent held positive attitudes towards this form of treatment and 45 per cent were not interested, with attitudes varying by age and region. Major constraints perceived by those with positive attitudes were the lack of facilities at a hospital level and problems of community services. Negative attitudes were associated with concerns about post-operative complications and pain, and assumptions about patients' preferences. This demonstrates a considerable range in surgeons' attitudes to day surgery despite its formal endorsement by professional bodies, and identifies what are perceived as the organizational and clinical barriers to its wider introduction. It is suggested that eliciting provider views and concerns forms an important requirement for the successful implementation of organizational change.

Ambulatory Surgical Procedures↗
PubMed1991

Are current techniques of inguinal hernia repair optimal? A survey in the United Kingdom.

Data was collected on the techniques currently employed in adult inguinal hernia repair by means of a postal questionnaire to consultants in four Regional Health Authorities in England. Questionnaires were returned by 240 consultants (85%). This identified a considerable range in methods of repair, with a Moloney nylon darn being the sole method used by 35% of consultants, and the Shouldice technique, either alone or in combination with other methods, being used by 20%. Overall, 51% employ a subcuticular suture for skin closure, and traditional skin sutures are used by 31%. There was no association between consultant's date of qualification or subspecialty and type of repair. Consultants qualifying after 1969 are most likely to use a subcuticular suture. Some 14% of all consultants and 19% of those qualifying since 1969 employ a Shouldice procedure and a subcuticular suture.

Adult↗
PubMed1990

Forecasting change.

Planning the use of resources is central to the NHS reforms. In the first of a series on forecasting the impact of change on the health service Dr Roger Beech, Jayne Thompson and John Smyth examine the use of computer modelling.

Computer Simulation↗
PubMed1990

Variations in lengths of stay and rates of day case surgery: implications for the efficiency of surgical management.

Variability in lengths of acute hospital stay and rates of day case surgery is shown to be a continuing pattern which occurs both between and within countries. A model of the determinants of health service activity is presented and the contribution of different factors to the observed variations is assessed. Differences in methods of funding health services are identified as a major determinant of the between country variations, while the within country variations largely reflect the influence of local differences in facilities and services and the organisation of care at a hospital level, as well as the independent effects of differences in clinical practice style. The main rationale for advocating a reduction in length of stay and increased use of day surgery is to increase efficiency by reducing costs per case while maintaining the quality of care. These criteria of costs, clinical outcomes and patient acceptability are examined in relation to day case surgery for an intermediate surgical procedure (inguinal hernia repair) and short stay surgery for cholecystectomy. The precise cost savings are shown to depend on the methods of costing, assumptions made and facilities employed, while factors influencing the outcomes achieved include the criteria of patient selection, the surgical techniques employed, and the adequacy of preoperative communication. Barriers to the more widespread adoption of short stay and day case surgery include practical and organisational constraints on clinical practice at a hospital level, lack of awareness among clinicians as to how far their practices differ from current norms, and clinical barriers raised by surgeons who do not see short stay policies as advantageous. Mechanisms to promote changes in clinical practice styles include independent professional audit, peer review, and involvement of clinicians in budgeting and resource allocation. Assessing quality requires that attention is given to patient acceptability and satisfaction as well as to the monitoring of clinical outcomes.

Ambulatory Surgical Procedures↗
PubMed1989

Demand for DNA probe testing in three genetic centres in Britain (August 1986 to July 1987).

We report a preliminary analysis of the data collected during the first year of the evaluation of clinical genetics in the context of DNA probes in three genetic centres, to show the pattern of the demand for genetic services in the three centres and the services used in meeting that demand. The analysis includes information on 10,185 persons from 2852 families. The results are presented according to mode of inheritance and according to the most common disorders for which DNA probes have been used in the three centres. The results indicate that the use of DNA probes is now a major element of activity in genetic departments, and that as long as indirect DNA probe testing is the predominant manner of using recombinant technology, the clinical input will be an important element of the costs, probably more so than that of the DNA laboratories, as a large number of family members needs to be tested. In most cases centres have concentrated activity on DNA testing for common and severe genetic disorders. However, there are disorders, such as familial hypercholesterolaemia, which have not been part of the established pattern of services. Conversely, a relatively high number of families have been studied for some disorders of very low incidence. This suggests that the number of DNA laboratories should be limited. The precise arrangements will need to be established. With such services the distribution of DNA testing facilities for different disorders can be controlled to limit duplication. The model followed in Scotland based on collaboration between centres is worth considering. We have detected very large differences in take up rate of services within and between regions. Although many factors may contribute to these differences, ease of access and lay and professional awareness are probably the most important. This is supported by the fact that more patients from the same or neighbouring DHAs attend the genetic centre than from those further away. We also concluded that published guidelines for clinicians in general on the uses of DNA probes, the type of families that could benefit, and the centres to which referrals should be sent would be very useful in increasing coverage and maximising the effectiveness of the services. Since this may increase demand, this educative tool should be coordinated and agreed by the Departments of Health with all the genetic departments and centres in the country.

DNA Probes↗