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Biomedical subjects

A Shiell

Publications and source records attributed to A Shiell.

At least 37 records · Page 2Linked to original sources
PubMed1998

Cost-effectiveness of measles outbreak intervention strategies.

In this study, we compared the likely cost-effectiveness of alternative strategies for controlling a school-based measles outbreak. The analysis involved assessing the expected costs and number of cases in a school-based outbreak of measles, with no intervention and with each of six control strategies. The marginal cost per case prevented ranged from $32.90 when only previously unvaccinated school children were offered vaccination to $6795 when vaccination was extended to the siblings of school children aged 6 to 12 months. This study provided further evidence of the cost-effectiveness of vaccination in outbreak control, and yielded useful information to inform control strategies in the event of a school-based outbreak. Decisions about which groups of children to aim at and whether to conduct school-based clinics will be influenced by local circumstances, particularly the baseline measles vaccination rate and the measles attack rate among infants.

Analysis of Variance↗
PubMed1998

Otitis media with effusion and size at birth.

To investigate whether recurrent or persistent otitis media with effusion (OME) was associated with particular patterns of fetal growth, we conducted a case control study of 129 children admitted for insertion of grommets and 150 controls. The risk of OME was not statistically significantly related to gestational age or individual measures of size at birth, but the ratio of head circumference to total length and the ponderal index at birth were statistically significantly lower in children with OME, both before and after adjustment for the potentially confounding effects of sex, age at current operation, and maternal gravidity. Mothers of cases were 2.2 times more likely than those of controls to have had one or more previous pregnancies that had not ended in a live birth (95% CI 1.3-3.8). We conclude that fetal growth, reflected by proportions at birth, may affect later risk of recurrent and persistent OME.

Anthropometry↗
PubMed1997

Do fee descriptors influence treatment choices in general practice? A multilevel discrete choice model.

Before 1990 Australian general practitioners (GPs) were remunerated according to consultation length. This was assumed to encourage GPs to prescribe more, counsel less and provide fewer treatments than were 'appropriate'. In an attempt to change this behaviour, the remuneration system was altered to reflect the content of consultations. This paper analyses, through the use of multilevel modelling, the effect of content-based descriptors on the discrete choice behaviour of GPs while controlling for patient, GP and practice characteristics. GPs who used content-based descriptors were just as likely to prescribe, counsel and treat compared to GPs who used time-based descriptors.

Australia↗
PubMed1997

Health outcomes are about choices and values: an economic perspective on the health outcomes movement.

The aim of the health outcomes movement is to reorientate health services so that the spotlight shines less on what is done and more on what is achieved. The health outcomes movement, thus far, has been most successful in addressing what appear to be technical questions relating to the measurement and analysis of health outcomes and in placing their routine use on the agenda of clinical practice and health services planning. If there is one lesson to be drawn from an economic perspective, however, it is that health outcomes are about values and not just technicalities. The need to make choices forces one to consider whether what is achieved is also what is most valued. The success of health service delivery, be it at a clinical, planning or systems level, must therefore be measured against agreed objectives. It follows that time must be taken to establish what patients and the community want from their health services and what each is prepared to give up to achieve its ends. Value judgements are unavoidable. The challenge lies not in measuring the outcomes of health interventions but in deciding what the objectives of the health system ought to be.

Australia↗
PubMed1997

The quiet revolution: reporting of health outcomes in general medical journals.

This study reviews the extent of evaluation of health outcomes in three general medical journals over the past decade by examining papers published in the original research section of the New England Journal of Medicine (NEJM), The Lancet, and the Medical Journal of Australia (MJA) in 1982 and 1992. Evaluations were identified and classified according to the type of comparison group and the type of outcome measures employed. They were divided into three categories: those employing a comparison group; those employing a before-and-after study design (or own comparison group); and those with no comparison group. The categories of outcome measures were mortality, clinical or intermediate measures of health state, and final outcome measures (quality of life). Results show that the proportion of papers evaluating a health services intervention remained stable over the period. However, the MJA published considerably fewer evaluations than the other journals. In the NEJM and The Lancet, 75 per cent of evaluations incorporated comparison groups, in the MJA, less than 40 per cent. Overall, the proportion of papers reporting final outcome measures increased significantly between 1982 and 1992 (p = 0.04) but the change in each journal individually did not reach statistical significance. This study indicates that the reporting of health outcomes evaluations has remained constant but there has been some change in the use of comparison groups and final outcome measures over time.

Australia↗
PubMed1996

Is general practitioner decision making associated with patient socio-economic status?

This paper presents a preliminary exploration into the relationship between decisions made by general practitioners (GPs) and the socio-economic status (SES) of patients. There is a large literature on the association between SES, health state and the use of health services, but relatively little has been published on the association between SES and decisions by clinicians once a patient is in the health system. The associations between GP decision making and the patient's SES, health status, gender and insurance status are examined using logit analysis. Three sets of binary choices are analysed: the decision to follow up; to prescribe; and to perform or to order a diagnostic test. Secondary data on consultations for a check up/examination were used to explore these relationships. The results suggest that SES is associated independently with the decision to test and the decision to prescribe but not with the decision to follow up. Patients of high SES are, ceteris paribus, more likely to be tested and less likely to receive a prescription compared with patients of low SES. Women are more likely to be tested and to receive a prescription than men. These findings have implications for the pursuit of equity as a goal of health services policy.

Adolescent↗
PubMed1995

Efficiency considerations in the expansion of radiation therapy services.

PURPOSE: An economic option appraisal to determine whether early investment in capital is an efficient means of expanding radiation therapy services. METHODS AND MATERIALS: Costs were based on 1991 data from a center in western Sydney. Two options were costed: Option 1 based on an increase in overtime performed by existing staff, using capital more intensively and possible use of shifts; Option 2 based on an investment in new capital and associated increases in levels of staffing. The health sector costs of both options were determined in one center at workloads of between 70,940 and 98,525 fields per year to assess relative efficiency. RESULTS: There was very little difference in cost between both options, with Option 1 slightly cheaper at workloads up to 98,525 fields per year. CONCLUSIONS: The results suggest that capital investment may be introduced at a fairly early stage without efficiency loss. Sensitivity analysis reinforces these conclusions and the generalizability of the results.

Costs and Cost Analysis↗
PubMed1994

The cost effectiveness of alpha interferon in the treatment of chronic active hepatitis C.

OBJECTIVE: To model the costs and effects of alpha interferon in the treatment of chronic active hepatitis C. DESIGN: A Markov modelling process to simulate the costs and outcomes in hypothetical cohorts of patients treated with and without alpha interferon. OUTCOME MEASURES: Costs per life saved and per life-year gained. RESULTS: On the basis of assumptions formulated about the disease processes and response to treatment, treatment with alpha interferon results in a discounted cost per life-year gained of $33,230 in patients with cirrhosis at the start of treatment and $71,950 in patients without advanced liver disease. The result is sensitive to the assumptions made about the long term effectiveness of alpha interferon. CONCLUSIONS: Alpha interferon is an expensive drug. Its effectiveness is clouded by uncertainty about the long term impact of the drug on the natural history of the disease. If adopted, its use should be monitored to allow the long term cost effectiveness of the drug to be evaluated properly.

Cost-Benefit Analysis↗
PubMed1994

The costs and effects of early discharge in the management of fractured hip.

The cost-effectiveness of a Fractured Hip Management Programme (FHMP) was evaluated by considering available measures of patient outcome and comparing the cost of the programme with the value of resources freed by reductions in length of hospital stay. The FHMP adopted a multidisciplinary team approach to care for elderly patients with hip fracture. The aims of the programme were to reduce delays before surgery; provide specialist geriatric medical supervision; improve early post-operative mobility; plan for hospital discharge with rehabilitation in the patient's normal environment; and provide continuity of care by a small number of staff. The cost of managing patients with fractured hip averaged $Aus11,060 per patient before the programme was introduced and $Aus9280 per patient after the FHMP was in place. This reduction in cost was achieved without impairing health outcomes. Patients treated by the programme were no worse off compared with those treated conventionally. In conclusion, the FHMP provided a cost-effective alternative in the management of fractured hip in elderly people.

Aged↗
PubMed1994

Consideration of the cost of interferon alfa-2b in the treatment of basal cell carcinoma.

Interferon alfa-2b is an effective but expensive way of treating basal cell carcinoma. In this paper, the cost-effectiveness of interferon relative to conventional treatment is considered. Circumstances where surgery is contra-indicated and would not otherwise be performed are not considered. The cost of achieving cure by interferon alfa-2b in the form of Intron A is compared with the cost of conventional treatment in four situations; simple lesions, lesions in which protacted healing is expected, lesions in areas where cosmetic result is important and large lesions where hospitalisation for skin grafting may be necessary. For simple lesions, treatment with interferon alfa-2b costs between $500 and $760 more per cure than conventional treatment. However, it is less expensive than conventional methods in cases that would require extensive home nursing or hospitalisation. The difference in cost in simple cases also represents the price which must be paid for the better cosmetic result achieved by interferon alfa-2b. In conclusion, interferon alfa-2b adds another effective option to the treatment of BCC but it is expensive. To exploit its advantages properly, it must be targeted on those who will benefit from it the most.

Basal Cell Carcinoma↗
PubMed1993

A cost function analysis of residential services for adults with a learning disability.

Successive UK governments have pursued a policy of community care for people with learning disabilities which, in the past ten years, has led to a marked change in the nature of residential provision. Research evidence on the costs and quality of alternative forms of community provision is inconclusive and contradictory. It is therefore timely to consider whether or not community residential facilities have delivered the expected quality of service at appropriate cost. The paper presents the results of a cost function analysis of a random stratified sample of staffed community facilities in England excluding London. Both costs and quality of care were found to vary greatly amongst community residential facilities. The most important factors explaining differences in cost were case-mix factors relating to client age, dependency and length of stay. Facility characteristics such as the type of building, the internal layout and the structural quality were not significant. Quality of service measures such as the extent to which care-regimes were client orientated and made use of local community services were positively and significantly associated with costs. Type of provider had no impact on costs independent of differences in case-mix and quality of care with the exception of the private for profit sector which appeared less expensive than other agencies. The shortcomings of the methods and implications of these findings for policy makers are discussed.

Activities of Daily Living↗
PubMed1993

The value of early discharge: dispelling some myths.

Our objective in this paper is to assess the value of early discharge schemes following the economic evaluation of three such schemes in New South Wales, Australia. An early discharge programme for obstetric patients, a fractured hip management programme and a continuing community cancer care programme were evaluated. The results of the economic evaluation of these schemes are discussed in the light of four commonly held beliefs about the value of early discharge: that early discharge schemes succeed in reducing length of stay, that early discharge schemes save money, that the welfare of patients is not reduced by early discharge and that early discharge schemes are cost-effective. The caution expressed by previous authors about the perceived advantages of early discharge schemes is still warranted.

Aged↗
PubMed1993

Satisfaction with postnatal care--the choice of home or hospital.

This paper reports the findings of a study of client satisfaction with postnatal midwifery care. Women could choose one of two forms of care; either domiciliary care following early discharge, or hospital care until discharge. Consumers' perceptions of their postnatal care were examined at the end of the period of care. Women assessed the midwives' interest and caring, education and information provided, their own progress with feeding and baby care, and their own physical and emotional health. They were also asked about their expectations of and gains from postnatal care. The findings indicated that women choosing domiciliary care and women choosing hospital care had different expectations of their postnatal care, but were largely satisfied with the quality of the care they chose. The women who chose domiciliary care rated their postnatal care more highly than the women who stayed in hospital. The findings reinforce the importance of providing women with choices for the maternity care which best suits their needs.

Adult↗
PubMed1993

The role of the clinical nurse co-ordinator in the provision of cost-effective orthopaedic services for elderly people.

Positions for nurses as coordinators and case managers have developed in response to demands for increased efficiency in the provision of hospital care. The Fractured Hip Management Programme in Western Sydney is one example of this development. The programme was introduced in response to mounting concern about the demands on hospital resources from elderly patients with hip fracture. A central feature of the programme is the pivotal role given to the nurse coordinator working within a multi-disciplinary team. This is not a new nursing role; rather it explicitly recognizes skills developed as part of the traditional nursing role. Evaluation of the programme found that patients received surgery sooner and spent less time in hospital, without adverse affects on outcome. The results show that recognition of the role of the nurse as patient advocate and care manager can lead to more cost-effective and higher-quality care.

Aged↗