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PubMed2006

Does telephone triage of emergency (999) calls using Advanced Medical Priority Dispatch (AMPDS) with Department of Health (DH) call prioritisation effectively identify patients with an acute coronary syndrome? An audit of 42,657 emergency calls to Hampshire Ambulance Service NHS Trust.

INTRODUCTION: The National Service Framework for Coronary Heart Disease requires identification of patients with an acute coronary syndrome (ACS) to enable prompt identification of those who may subsequently require pre-hospital thrombolysis. The Advanced Medical Priority Dispatch System (AMPDS) with Department of Health (DH) call prioritisation is now the common triage tool for emergency ('999') calls in the UK. We retrospectively examined patients with ACS to identify whether this triage tool had been able to allocate an appropriate emergency response. METHODS: All emergency calls to Hampshire Ambulance Service NHS Trust (HAST) from the Southampton area over an 8 month period (January to August 2004) were analysed. The classification allocated to the patient by AMPDS (version 10.4) was specifically identified. Data from the Myocardial Infarct National Audit Project) were obtained from the receiving hospital in Southampton to identify the actual number of patients with a true ACS. RESULTS: In total, 42 657 emergency calls were made to HAST from the Southampton area. Of these, 263 patients were subsequently diagnosed in hospital as having an ACS. Of these 263 patients, 76 presented without chest pain. Sensitivity of AMPDS for detecting ACS in this sample was 71.1% and specificity 92.5%. Positive predictive value was 5.6% (95% confidence interval 4.8 to 6.4%), and 12.5% (33/263) of patients with confirmed ACS were classified as non-life threatening (category B) incidents. CONCLUSION: Only one of approximately every 18 patients with chest pain has an ACS. AMPDS with DH call prioritisation is not a tool designed for clinical diagnosis, and its extension into this field does not enable accurate identification of patients with ACS.

Chest Pain↗

PubMed1998

A prioritisation system for elective coronary angiography.

OBJECTIVE: To devise a clinical prioritisation system for rationing access to a cardiac catheter waiting list and to describe its performance at predicting angiographic findings and selecting patients for angioplasty or coronary artery bypass graft surgery. SETTING: Tertiary level cardiology centre. METHODS: (1) 665 consecutive patients on an elective waiting list for coronary angiography were scored using a system derived from established clinical criteria for selecting patients for coronary surgery (New Zealand/Duke). The scores were compared with clinical outcome (referral for surgery, angioplasty, or medical management). (2) In a subset of 125 patients, scores derived from clinical criteria and exercise testing were compared with findings on coronary angiography. (3) Multivariate analysis was used in a new group of 178 patients to identify factors that would be better predictors of the angiographic score. (4) A new scoring system was devised based partly on the results of the multivariate analysis. It was applied to a new test group of 100 patients using clinical outcome and angiographic score as outcome measures. RESULTS: (1) Using the established clinical score, similar proportions of patients were referred after angiography for medical management, angioplasty, or coronary bypass grafting, irrespective of their original score. The exceptions were patients with a score < 20, who were more likely to continue medical management. (2) There was poor correlation (r = 0.05) between the clinical score and the subsequent angiographic score. (3) Multivariate analysis identified age, male sex, previous myocardial infarction, high cholesterol, and diabetes as independent predictors of coronary score. (4) The modified scoring system, incorporating the predictors identified by multivariate analysis, performed better than the original scoring system in predicting coronary score when both were tested, but some patients had severe disease despite a low score. CONCLUSIONS: Patients can be ranked using clinical and non-invasive criteria, and a rationing system implemented on this basis. With prioritisation by noninvasive criteria, the risk of missing serious coronary disease in patients with relatively mild symptoms must be accepted; this risk becomes greater the more stringently rationing is applied.

Aged↗

PubMed1993

The relevance of health state after treatment in prioritising between different patients.

In QALY-thinking, an activity that takes N people from a bad state (including 'dying') to the state of healthy for X years should have priority over an activity that takes N other people from the same bad state to a state of moderate illness for the same number of years (given equal costs). An empirical study indicates that this view may not be shared by the general public in Norway. Subjects tended to emphasise equality in value of life and in entitlement to treatment rather than level of health after treatment. The relevance of costs per QALY in prioritising between different health care programmes in Norway is thereby brought in to doubt. While the sample in the study is too small to support firm policy conclusions, the results should contribute to an increased interest among health economists in actually measuring people's ethical preferences in matters of prioritising, rather than taking it for granted that their own values are shared by the general public.

Adult↗

PubMed2000

Prioritising referrals to a community mental health team.

BACKGROUND: Current national policies encourage prioritisation of people with severe mental illness (SMI) as well as the development of a primary care-led National Health Service. Where resources for mental health are limited, there is a potential conflict between the needs of people with SMI and the much more common depressive and anxiety disorders that form the bulk of the mental health workload in primary care. AIM: To describe the re-organisation of a community mental health team in order to prioritise people with SMI. METHOD: The number and type of referrals received in the 12 months before and after re-organisation were compared, and general practitioners' (GP) views on the changes sought. RESULTS: There was a significant reduction in GP referrals of patients with less severe disorders in the second year. In both years the proportion of patients with a possible psychotic diagnosis or risk of self-harm was much higher among referrals from within the psychiatry department (92% of referrals) than among GP referrals (20% of referrals). Using data from a postal survey, 46% of referring GPs reported a significant improvement in the service provided to patients with SMI, but 34% reported a deterioration in services for other patient groups. GPs were more likely to be satisfied with the service for people with SMI than with the service for other patient groups. CONCLUSIONS: Improvements in the service provided for those with SMI can be achieved, but this may be at the expense of services for other patient groups. Primary care groups will need to consider this potential conflict in setting priorities for mental health.

Community Mental Health Services↗

PubMed2006

Two-week rule: has prioritisation of breast referrals by general practitioners improved?

INTRODUCTION: A 9-month audit, soon after the introduction of the 2-week rule in the UK in 1999, showed that a significant number of breast cancer patients were referred as non-urgent by their GPs, when the goal is that all suspected breast cancer patients should be seen by a hospital specialist urgently within 2 weeks of referral. The aim of this study was to determine whether GP grading of referrals into urgent and non-urgent had improved. METHOD: A retrospective review of GP referrals over 8 months, between September 2003 and April 2004, with regard to their urgency, subsequent diagnosis and the use of proformas (standardised referral formats) was carried out. The results were compared to the 1999 audit. RESULTS: Eighty-two of 1178 patients referred by GP had breast cancer, versus 115 of 1176 patients referred in 1999. Sixty-eight per cent (56/82) of breast cancer patients were referred as urgent, compared to 47% (54/115) in 1999 (P=0.005). A proforma was used in 47% (548/1178) of GP referrals while no proforma was used in 1999. Sixty-five of the 82 cancer patients were referred with a proforma and 85% (55/65) were referred as urgent. CONCLUSION: GP prioritisation of referrals has improved since 1999. With the use of proformas a significant number of patients with cancer were referred urgently.

Breast Neoplasms↗

PubMed2006

Evidence that older adult fallers prioritise the planning of future stepping actions over the accurate execution of ongoing steps during complex locomotor tasks.

Previous research has highlighted differences between older adults determined to be at a low-risk of falling (low-risk) and older adults prone to falling (high-risk) in both where and when they look at stepping targets and the precision with which they subsequently step. On the basis of these findings, we proposed that high-risk older adults prioritise the planning of future stepping actions over the accurate execution of ongoing movements and that adoption of this strategy contributes to increased likelihood of falls. The present experiment was designed to test this hypothesis by manipulating the complexity of the required walking conditions and comparing gaze and stepping performance between young, high-risk and low-risk older adults. Participants walked at a self-selected pace along a 7-m pathway and encountered one of three obstacle conditions: (1) a single stepping target, (2) two stepping targets, (3) two stepping targets separated by a raised obstacle. On average, when there was a single target (Target 1) in the travel path, all groups fixated the target until after heel contact. However, when challenged with additional impending stepping constraints, high-risk older adults transferred their gaze significantly sooner from Target 1 prior to heel contact. On average, low-risk older adults and younger adults maintained gaze on Target 1 until after heel contact, irrespective of future constraints. Premature gaze transfer was associated with decline in stepping accuracy and precision. Our findings suggest that high-risk older adults choose a potentially hazardous gaze strategy when challenged with multiple obstacles. Putative mechanisms underlying this behaviour are discussed.

Accidental Falls↗

PubMed2006

Prioritisation by physicians in the Netherlands--the growth hormone example in drug reimbursement decisions.

Drug treatment and reimbursement is an area of ever growing complexity in health priority setting. This paper assesses the National Registry of Growth Hormone Treatment (LRG) responsible for making prioritisation decisions in the Dutch drug reimbursement system in the treatment of growth hormone, using the framework for fairness. We used qualitative research consisting of semi-structured interviews and focus group sessions combined with quantitative methods to audit the decisions of the forum. The rationing decisions of the forum demonstrate accountability for reasonableness by the conditions for transparency, relevance, and appeal. Most rationales for the decisions are public and transparent. The patients and paediatricians see decisions made by the LRG as clinical and therefore relevant decisions. They also refer to extensive appeal procedures. The case also raises important issues regarding the legitimacy of expert-based priority setting as the cyclic nature of guideline development conflicts with the need for maintaining strict rationing criteria. In 13% of the patients, the sick funds did cover treatment as the forum advised them to do, but according to guideline criteria it may be unlikely that these patients have growth hormone deficiency. According to the LRG, however, only 2% of the decisions are inconsistent with the guidelines, as some criteria on what to do in case of more uncertainty, shifted. For the forum, it seems rather unthinkable to go against the professional norms, in spite of formal national regulations. For the Health Care Insurance Board (CVZ), it was not considered possible to go against national regulations, especially as professional norms have shifted without informing policy makers and patient representatives.

Choice Behavior↗

PubMed2005

Substance prioritisation for the development of EU Acute Exposure Toxicity Thresholds (AETLs).

The aim of the EU Acute Exposure project, ACUTEX, is to develop a methodology for establishing European Acute Exposure Threshold Levels, EU AETLs, for toxic substances in relation to harm to people by inhalation. The development of AETLs is initially in the context of the risks of major accidents from chemical sites and in particular their regulation through the EU 'Seveso II' Directive. It is intended that AETLs can be used within Member States, where appropriate, to inform decisions on land-use planning and emergency planning. AETLs will not have a regulatory status. This paper describes: the selection of 21 preliminary substances to use as case studies in the development and testing of the AETL's methodology; and the development of a prioritisation methodology to inform initial substance selection for a possible further AETLs program. The work was based on consultation with experts drawn from EU major stakeholder groups. It included a Validation Exercise working with three Member States, which account for between approximately 40% and 50% of all EU Seveso II sites. From this Validation Exercise we infer that, if these three Member States are representative in terms of numbers of priority substances, then the number of EU higher priority substances for further AETLs development is unlikely to be much in excess of 50.

Environmental Exposure↗

PubMed2003

Is the allocation of metabolisable protein prioritised to milk production rather than to immune functions in Teladorsagia circumcincta-infected lactating ewes?

It has been suggested that the periparturient breakdown of immunity to parasites has a nutritional basis. Our overall hypothesis is that it results from a prioritised scarce nutrient allocation to reproductive functions (e.g. milk production) rather than to immune functions. We tested this hypothesis by offering five levels of dietary metabolisable protein, ranging from 0.65 to 1.25 times their assumed requirements, for 4 weeks post-parturition to twin-rearing Greyface ewes, experimentally infected with Teladorsagia circumcincta. We hypothesised that the initial increments of metabolisable protein supply would increase milk production without affecting the degree of breakdown of immunity whilst later increments would reduce the degree of breakdown of immunity. The first two increments of metabolisable protein supply indeed increased milk production and did not affect final worm burdens, but in contrast to the expectation, reduced faecal egg counts and total egg output. The last two increments of metabolisable protein supply did not further affect milk production and egg output, but resulted in reduced final worm burdens. Metabolisable protein supply did not affect plasma IgG and IgE antibody against somatic L(3) antigen but the first three increments reduced plasma pepsinogen and plasma IgA antibody. The last increment did not further reduce plasma pepsinogen but increased plasma IgA. Metabolisable protein supply did not systematically affect abomasal mucosal mast cell, globule leukocyte and eosinophil counts. Our results support the view that the priority of scarce metabolisable protein allocation to milk production over immune functions may be gradual rather than absolute. The contrast between effects of metabolisable protein supply on faecal egg count and final worm burden points towards the possibility that if different effector responses regulate fecundity and worm expulsion, then they would differ in their sensitivity towards changes in the degree of nutrient scarcity.

Animals↗

PubMed2003

Prioritisation of veterinary medicines in the UK environment.

A wide range of veterinary medicines is used to treat animals in the UK. Whilst the environmental impact of selected substances (particulary the sheep dip chemicals, anthelmintics and fish farm chemicals) has been well studied, limited information is available in the public domain on the other groups of substances (e.g. antifungals, coccidiostats, antiprotozoals, hormones and growth promoters). There is therefore a need to identify other substances that may impact the environment in order to design national monitoring programmes, target experimental work and develop pollution prevention methodologies. In this study, a simple two-stage prioritisation scheme was developed and applied to veterinary medicines in use in the UK. In the first stage, those substances that have high potential to enter the environment in significant amounts were identified on the basis of amounts used in the UK, treatment type and metabolism. In stage 2, the hazard of the identified substances to terrestrial and aquatic organisms was assessed. Using the approach, a total of 56 substances or groups were assigned to a 'high priority' category. For eleven of these substances, sufficient data were available to characterise their risk, these were: oxytetracycline, chlortetracycline, tetracycline, sulphadiazine, amoxicillin, diazinon, tylosin, dihydrostreptomycin, apramycin, cypermethrin and sarafloxicin. For the remaining 45 substances, full datasets were not available and it is recommended that in the first instance, attempts are made to fill these data gaps.

Environmental Exposure↗

PubMed2002

Prioritising home care needs: research with older people from three ethnic minority community groups.

This paper draws on research with three minority ethnic community groups in Manchester. The aim of the study was to examine and prioritise social care needs. Focus groups were chosen as a way of beginning discussion about these issues. The findings suggest that some quality issues are relevant to all communities of older people. However, some were specific to the community groups. This paper describes some of the lessons learned about running focus groups with people whose first language is not English and suggests some considerations for future research.

Aged↗

PubMed1997

Prioritising the cardiac surgery waiting list: the angina patient's perspective.

OBJECTIVE: To determine patients' views on how clinical and demographic factors should affect priorities for cardiac revascularisation. DESIGN: A descriptive survey of patients' views conducted immediately after angiography and treatment counselling. SUBJECTS: 136 patients who were awaiting coronary angioplasty in either of the two regional cardiology centres in Northern Ireland. RESULTS: About half the subjects (52%) felt that certain social factors such as having dependent relatives should be taken into account when deciding priority for surgery. A sizeable minority felt that younger subjects and non-smokers (40% and 44%, respectively) should be accorded higher priority, with older subjects and smokers being more likely to hold such views. CONCLUSIONS: While there is little evidence that demographic and lifestyle factors affect the relative efficacy of surgery, the challenge remains to devise a prioritisation guideline that can properly reflect societal values and the evidence base.

Age Factors↗

PubMed2006

The systematic functional characterisation of Xq28 genes prioritises candidate disease genes.

BACKGROUND: Well known for its gene density and the large number of mapped diseases, the human sub-chromosomal region Xq28 has long been a focus of genome research. Over 40 of approximately 300 X-linked diseases map to this region, and systematic mapping, transcript identification, and mutation analysis has led to the identification of causative genes for 26 of these diseases, leaving another 17 diseases mapped to Xq28, where the causative gene is still unknown. To expedite disease gene identification, we have initiated the functional characterisation of all known Xq28 genes. RESULTS: By using a systematic approach, we describe the Xq28 genes by RNA in situ hybridisation and Northern blotting of the mouse orthologs, as well as subcellular localisation and data mining of the human genes. We have developed a relational web-accessible database with comprehensive query options integrating all experimental data. Using this database, we matched gene expression patterns with affected tissues for 16 of the 17 remaining Xq28 linked diseases, where the causative gene is unknown. CONCLUSION: By using this systematic approach, we have prioritised genes in linkage regions of Xq28-mapped diseases to an amenable number for mutational screens. Our database can be queried by any researcher performing highly specified searches including diseases not listed in OMIM or diseases that might be linked to Xq28 in the future.

Animals↗

PubMed2006

Developing a prioritisation framework in an English Primary Care Trust.

BACKGROUND: In the English NHS, Primary Care Trusts (PCTs) are required to commission health services, to maximise the well-being of the population, subject to the available budget. There are numerous techniques employed to make decisions, some more rational and transparent than others. A weighted benefit score can be used to rank options but this does not take into account value for money from investments. METHODS: We developed a weighted benefit score framework for use in an English PCT which ranked options in order of 'cost-value' or 'cost per point of benefit'. Our method differs from existing techniques by explicitly combining cost and a composite weighted benefit score into the cost-value ratio. RESULTS: The technique proved readily workable, and was able to accommodate a wide variety of data and competing criteria. Participants felt able to assign scores to proposed services, and generate a ranked list, which provides a solid starting point for the PCT Board to discuss and make funding decisions. Limitations included potential for criteria to be neither exhaustive nor mutually exclusive and the lack of an interval property in the benefit score limiting the usefulness of a cost-value ratio. CONCLUSION: A technical approach to decision making is insufficient for making prioritisation decisions, however our technique provides a very valuable, structured and informed starting point for PCT decision making.

Journal Article↗

PubMed2006

Helping to prioritise interventions for depression and schizophrenia: use of Population Impact Measures.

BACKGROUND: To demonstrate the potential of Population Impact Measures in helping to prioritise alternative interventions for psychiatry, this paper estimates the number of relapses and hospital readmissions prevented for depression and schizophrenia by adopting best practice recommendations. The results are designed to relate to particular local populations. METHODS: Literature-based estimates of disease prevalence, relapse and re-admission rates, current and best practice treatment rates, levels of adherence with interventions and relative risk reduction associated with different interventions were obtained and calculations made of the Number of Events Prevented in your Population (NEPP). RESULTS: In a notional population of 100,000 adults, going from current to 'best' practice for different interventions, the number of relapses prevented in the next year for schizophrenia were 6 (increasing adherence to medication), 23 (family intervention), 43 (relapse prevention), and 44 (early intervention); and for depression the number of relapses prevented in the next year were 100 (increasing care management), 227 (continuing treatment with antidepressants), 279 (increasing rate of diagnosis), and 325 (Cognitive Behaviour Therapy). Hospital re-admissions prevented in the next year for schizophrenia were 6 (increasing adherence to medication), 36 (relapse prevention) and 40 (early intervention). CONCLUSION: Population Impact measures provide the possibility for a policy-maker to see the impact of a new intervention on the population as a whole, and to compare alternative interventions to best improve psychiatric disease outcomes. The methods are much simpler than others, and have the advantage of being transparent.

Journal Article↗

PubMed2006

Using value of information analysis to prioritise health research: some lessons from recent UK experience.

Decisions to adopt, reimburse or issue guidance on the use of health technologies are increasingly being informed by explicit cost-effectiveness analyses of the alternative interventions. Healthcare systems also invest heavily in research and development to support these decisions. However, the increasing transparency of adoption and reimbursement decisions, based on formal analysis, contrasts sharply with research prioritisation and commissioning. This is despite the fact that formal measures of the value of evidence generated by research are readily available. The results of two recent opportunities to apply value of information analysis to directly inform policy decisions about research priorities in the UK are presented. These include a pilot study for the UK National Co-ordinating Centre for Health Technology Assessment (NCCHTA) and a pilot study for the National Institute for Health and Clinical Excellence (NICE). We demonstrate how these results can be used to address a series of policy questions, including: is further research required to support the use of a technology and, if so, what type of research would be most valuable? We also show how the results can be used to address other questions such as, which patient subgroups should be included in subsequent research, which comparators and endpoints should be included, and what length of follow up would be most valuable.

Decision Making, Organizational↗

PubMed2002

['Necessity' determined on the basis of disease severity when prioritising health care interventions].

In the Netherlands, the Priorities in Healthcare [Keuzen in de Zorg] Committee proposed that the prioritisation of healthcare interventions should in part be based on the criterion 'necessity'. However, this criterion has hardly ever been used. It was proposed that 'necessity' should be defined in terms of disease severity. This concept examines the fraction of expected quality-adjusted life years (QALY) that a patient will lose if the condition concerned is not treated. The following two possible applications for healthcare policy were studied. Firstly, relatively necessary care could be fully reimbursed, whereas less necessary care would only be reimbursed in part. Secondly, for relatively necessary interventions a lower cost-effectiveness threshold (relatively high costs per QALY for necessary care) could be accepted. In these cases the concept of disease severity provides a new feasible interpretation of the criterion 'necessity'.

Cost-Benefit Analysis↗

PubMed2000

Prioritisation of research recommendations from a national needs assessment programme.

OBJECTIVE: To gain consensus on and rank research and development recommendations from a series of Scottish Needs Assessment Programme (SNAP) reports. DESIGN: A two stage Delphi questionnaire was used and participants were asked to rank the recommendations in terms of potential health gain, practicality and priority. SUBJECTS: Views were sought from all consultants in dental public health in Scotland and from non-consultant members of the SNAP oral health steering group. RESULTS: Of the 17 individuals eligible, 16 participated in the study. Fifty four recommendations for research and development were identified in seven SNAP reports. Recommendations relating to the prevention of dental caries in young children, the organisation and delivery of dental care to disadvantaged groups and increased understanding of the aetiology and pathogenesis of oral cancer in younger people were seen as of highest priority. CONCLUSIONS: This study has drawn together and prioritised a series of recommendations, and will help inform future oral health research needs in Scotland.

Delphi Technique↗