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Biomedical subjects

T A Sheldon

Publications and source records attributed to T A Sheldon.

At least 19 recordsLinked to original sources
PubMed1996

Informed choice for users of health services: views on ultrasonography leaflets of women in early pregnancy, midwives, and ultrasonographers.

With the aim of promoting the informed choice of pregnant women, staff and pregnant women at two urban hospitals were offered leaflets summarising the best available evidence about the effectiveness of routine ultrasonography in early pregnancy. Ultrasonographers doubted the credibility of the evidence and were concerned that the leaflets would raise women's anxiety, reduce uptake of scans, disrupt hospital organisation, and reinforce media messages about the poor safety record of ultrasonography. Midwives thought that the leaflets would inform women, help them to talk about their care with health professionals, and help them to get better care. Women were shocked at some of the contents but thought that it was appropriate to include both advantages and disadvantages of routine scanning in the leaflet. This case study highlights the resistance of some health professionals to evidence based health care; underlying conflicts with the principle of professional autonomy; concern that informed choice may create anxiety; and professional and organisational barriers to allowing informed choice.

Attitude of Health Personnel↗
PubMed1996

An index of need for psychiatric services based on in-patient utilisation.

BACKGROUND: The paper describes the development of an index of the relative need for psychiatric services for the purposes of distributing NHS funds in England. METHOD: The study is based on an empirical analysis of all psychiatric in-patient completed episodes in England in 1991/92. Any index of need should be independent of the effect of variations in health care supply on the use of psychiatric services. In order to disentangle the influences of supply from social and clinical determinants of utilisation, two stage least squares regression and multilevel modelling techniques were used. RESULTS: The outcome was an index comprising six health and socio-economic variables. This is now being used by the NHS Executive to distribute about pound 2.2 billion of annual NHS expenditure for psychiatric services between English health authorities. CONCLUSION: It is shown that the index is much more sensitive to needs and therefore more redistributive than the previous index of need used in the NHS.

Adolescent↗
PubMed1995

Cost effectiveness of antenatal screening for cystic fibrosis.

OBJECTIVE: To estimate the cost effectiveness of different antenatal screening programmes for cystic fibrosis. SETTING: Antenatal clinics and general practices in the United Kingdom. DESIGN: Four components of the screening process were identified: information giving, DNA testing, genetic counselling, and prenatal diagnosis. The component costs were derived from the literature and from a pilot screening study in Yorkshire. The cost of a given screening programme was then obtained by summing the components according to the specific screening strategy adopted (sequential and couple), the proportion of carriers detected by the DNA test, and the uptake of screening. Baseline assumptions were made about the proportion with missing information on carrier status from previous pregnancies (20%), the proportion changing partners between pregnancies (20%), and the uptake of prenatal diagnosis (100%). Sensitivity analysis was performed by varying these assumptions. MAIN OUTCOME MEASURE: Cost per affected pregnancy detected. RESULTS: Under the baseline assumptions sequential screening costs between pounds 40,000 and pounds 90,000 per affected pregnancy detected, depending on the carrier detection rate and uptake. Couple screening was more expensive, ranging from pounds 46,000 to pounds 104,000. From the sensitivity analysis a 10% change in the assumed proportion with missing information from a previous pregnancy alters the cost by pounds 4000; a 10% change in the proportion with new partners has a similar effect but only for couple screening; and cost will change directly in proportion to the uptake of prenatal diagnosis. CONCLUSIONS: While economic analysis cannot determine screening policy, the paper provides the NHS with the information on cost effectiveness needed to inform decisions on the introduction of a screening service for cystic fibrosis.

Cost-Benefit Analysis↗
PubMed1995

Volume and outcome in coronary artery bypass graft surgery: true association or artefact?

OBJECTIVES: To examine the evidence for a relation between volume of coronary artery bypass graft surgery and hospital death rates, and to assess the degree to which this could be due to confounding because of differences in case mix. SUBJECTS: People receiving coronary artery bypass graft surgery in the United States. DESIGN: A systematic review of empirical studies examining the relation between volume and outcome of coronary artery bypass graft surgery. Studies were scored according to degree of adjustment for case mix. Above 200 procedures a year was regarded as high volume. RESULTS: Fifteen studies were identified, all of which used observational data from the United States for 1972-92. Six were included in the analysis, one was included in a sensitivity analysis, and eight were excluded because of duplicate analyses of data sources and methods of reporting results. The seven studies analysed reported a reduced mortality with increased volume. Studies with better adjustment for case mix, however, indicated less reduction in mortality with increased volume (P = 0.04). The apparent advantages of higher volume also decreased over time (P < 0.001). CONCLUSIONS: The evidence for reduced mortality in hospitals with a high volume of coronary artery bypass graft surgery is based entirely on observational studies. These studies may have over-estimated the benefit of increased volume because of poor adjustment for case mix. It signals the need for caution in interpreting the results of observational studies that examine the relation between volume and outcome.

Confounding Factors, Epidemiologic↗
PubMed1995

Nebulised amiloride in respiratory exacerbations of cystic fibrosis: a randomised controlled trial.

OBJECTIVE: To assess the benefit of nebulised amiloride added to the standard inpatient treatment of a respiratory exacerbation in cystic fibrosis. DESIGN: Prospective, randomised, double blind, placebo controlled trial. SUBJECTS: 27 cystic fibrosis patients (mean age 12.8 years). SETTING: Two hospitals in Leeds, UK. RESULTS: Both forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) showed improvements over the course of treatment, although there was no difference in respiratory function between the two groups at any of three time periods during the study. The time to reach peak FVC was significantly reduced in the amiloride group (4.2 v 7.6 days; 95% CI 0.4 to 6.4 days), but not in the time to reach peak FEV1 (5.7 v 7.9 days; 95% CI -1.2 to 5.6 days). CONCLUSIONS: Amiloride did not result in a greater overall improvement in respiratory function. There was a suggestion that it may have an effect on the rate of improvement, and thus may possibly influence the duration of treatment. This hypothesis deserves further evaluation.

Adolescent↗
PubMed1995

Interpreting the new illness question in the UK census for health research on small areas.

STUDY OBJECTIVE: The study aimed to identify the various factors that seem to influence the average response to the new census question on limiting, long standing illness at the small area level, to assess the extent to which the new questions adds to information already available in the census and elsewhere, and to discuss how useful the data are likely to be for those planning health and social services. DESIGN: This was a cross sectional analysis of the relationship between rates of limiting, long standing illness (standardised for age and sex) and a large number of indicators of health and socioeconomic status at the small area level. SETTING: The study used data relating to 4985 small areas covering the whole of England. The average population was about 10 000. PARTICIPANTS: The 1991 census of population was addressed to the entire population of England. MAIN RESULTS: There are wide variations in the levels of self reported long standing illness between small areas, 70% of which are explained by demographic factors. Variation in age/sex standardised responses to the new census question at the small area level can largely be explained by census data on self reported disability among those of working age, standardised mortality ratio, and by indicators of socioeconomic circumstances relating to social class, ethnicity, and the elderly living alone. These does not seem to be a significant reporting bias due to underemployment. CONCLUSION: Unlike the disability question in the census, the standardised, self reported long standing limiting illness ratio covers the entire population and it is not skewed towards men. Although the variable is a synthesis of the health and social determinants of perceived morbidity, it does not provide much information that was not already available. In addition, it is available every 10 years only and thus may be rather inaccurate as an indicator of relative need towards the end of the decade. Moreover, in future censuses, individuals' answers might be influenced by the knowledge that their responses will affect the volume of resources allocated to the area in which they live.

Adolescent↗
PubMed1994

Allocating resources to health authorities: development of method for small area analysis of use of inpatient services.

Every year about 22 billion pounds is allocated to health authorities for hospital and community services in England. The distribution of most of these funds is based on a formula developed to reflect the population's needs, but the existing formula has been criticised on several grounds. This paper describes the development of a method to determine the health needs for small geographical areas. Data from the hospital episodes statistics and 1991 census together with information on vital statistics and supply of health care facilities were used in the model. Two stage least squares regression was used to identify true indicators of need, and these were entered into a multilevel model to take account of variations in practice in different health authorities. The resulting formula should be more statistically robust and more sensitive to needs than previous approaches.

Health Care Rationing↗
PubMed1994

Allocating resources to health authorities: results and policy implications of small area analysis of use of inpatient services.

A study designed to identify the principal determinants of use of inpatient facilities in NHS hospitals in England used the data and methods outlined in the previous paper. The model for the psychiatric sector contains mortality, self reported morbidity, and social variables indicating deprivation and the level of care at home. The non-acute model contains mortality and several socioeconomic variables. The models lay less weight on age than the current formula, and a national formula based on these models would, in the acute sector, redistribute resources to poorer areas compared with the current formula.

Health Care Rationing↗
PubMed1994

Attempt at deriving a formula for setting general practitioner fundholding budgets.

OBJECTIVE: To explore the possibility of using routine Hospital Episode Statistics, census data, and vital statistics to derive weights for an equitable capitation formula for setting general practitioner fundholding budgets for buying acute hospital services. DESIGN: Analysis of a routine dataset of 9 million hospital episodes in 1991-2, extracting elective general practitioner fundholding procedures, combined with 1991 census variables, vital statistics, and data on supply of health care at ward level. Costs were attached to each procedure according to the average cost of the relevant "Mersey" band category. MAIN OUTCOME MEASURES: Variation in age and sex adjusted expenditure per head on fundholding procedures across wards modelled for the impact of health and social needs variables after adjusting for variations in supply. RESULTS: No sensible simple model including determinants of use other than age and sex could be derived. The most parsimonious but statistically acceptable model showed that though standardised mortality ratio and self reported illness and several social class variables were associated with utilisation, the signs and the size of the coefficients were contradictory. The most important explanation of variation was provided by age and sex differences between wards. CONCLUSIONS: An equitable system of setting general practitioner fundholders' budgets is needed. In the short term age and sex weighted capitation should form the principal basis of fundholder budgets. Utilisation data at ward level are inadequate for developing a formula which adequately adjusts for the differences in the health care needs of populations. A capitation formula based on information derived from individual cohort data may be the only means of promoting equity and efficiency and of avoiding discriminating against patients with known high cost health problems.

Adolescent↗
PubMed1994

Prescribing selective serotonin reuptake inhibitors as strategy for prevention of suicide.

OBJECTIVE: To evaluate a policy to reduce the incidence of suicide by means of changing the prescribing of antidepressants from the older tricyclic antidepressants to the routine first line use of selective serotonin reuptake inhibitors or newer tricyclic and related antidepressants. DESIGN: Cost effectiveness analysis with sensitivity analyses using observational data on costs, volume of prescribing, deaths, and toxicity. SETTING: United Kingdom primary care. INTERVENTIONS: Selective serotonin reuptake inhibitors or newer tricyclic and related antidepressants compared with the use of older tricyclics. MAIN OUTCOME MEASURES: Cost per life saved and cost per life year saved. RESULTS: The potential number of lives which may be saved from a switch to the routine first line use of selective serotonin reuptake inhibitors is between 300 and 450 each year. The cost per life year gained ranges from 19,000 pounds to 173,000 pounds, depending on the assumptions used. The cost per life year gained through the use of the newer tricyclic and related antidepressants is considerably lower. CONCLUSIONS: The cost per life year gained through avoiding suicides by the routine first line use of serotonin reuptake inhibitors is likely to be high. The new tricyclics and related drugs are of similar toxicity to the serotonin reuptake inhibitors but are considerably cheaper and so are most cost effective for this purpose. Further research is required on such prescribing. Because of the great uncertainties the shift to considerably more expensive options must be further investigated.

Antidepressive Agents, Tricyclic↗
PubMed1994

Paediatric inpatient utilisation in a district general hospital.

Paediatric inpatient utilisation in a district general hospital was studied for 20 general practices covering a population of 26,433 children. The factors influencing the rate and route of admission (general practitioner (GP) or accident and emergency department) were analysed for 894 emergency non-traumatic admissions over a 12 month period. The overall rate of acute, nontraumatic admission was 33.8/1000; 35% of these admissions were via the accident and emergency department. Asthma was the most common reason for admission (16.1%); 56.9% of the admissions resulted from respiratory tract illness and 44% were for an infective illness. There was a significant variation in the route and rate of admission across practices. Admission rates ranged from 10 to 70/1000 children under 15 and the proportion via the accident and emergency department from 19% to 85%. The proportion of admissions via the accident and emergency department for each practice was highly negatively correlated with the number of GPs in the practice, the number of children under 15 registered, and positively correlated with the unemployment rate attributed to the list. Using multiple logistic regression analysis, the risk of being admitted via the accident and emergency department relative to GP admission was shown to be higher for older children (odds ratio for each year of age 1.05) and less for children registered with large practices with more GPs (odds ratio for each extra GP 0.36) or practices with more children under 15 (odds ratio per extra child 0.9991). Access to hospital as measured by isochrone bars and social characteristics of the ward of residence of each child admitted were not associated with the route of admission. The admission rate for each practice was positively, but not statistically significantly, associated with the unemployment rate attributed to the list, the unemployment rate of the ward where the practice was located, and the percentage of admissions via accident and emergency, and negatively associated with the percentage of the list under 15 years.

Adolescent↗