Screening for sickle cell disease and thalassaemia: a systematic review with supplementary research.
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Anemia, Sickle Cell↗
Biomedical subjects
C Normand
Publications and source records attributed to C Normand.
Using social health insurance to meet policy goals.
Social health insurance, with contributions based on incomes and access to services on need is being considered as an option for health care finance in many countries. The argument in this paper starts from the premise that the choice of health care financing mechanisms should start with a clear focus on policy goals, with different options judged against the extent to which these are met. These are likely to include objectives of access to care for those in need, quality of care, incentives for efficient provision and cost control. Different systems will meet the objectives of mobilising resources, providing insurance against risk and redistribution resources to differing extents. It is argued that a particular problem in health care finance is shifting rights to resources over time. It is also important to be clear about the distinction between affordability of and payment mechanisms for health care. The choice of funding mechanisms may have little effect on other policy goals, such as economic development. However, they may differ in the degree to which they allow specific health policy goals to be met. Different mechanisms for collecting and managing funds, and for paying for services are discussed. The paper concludes with concerns that too much emphasis is placed on structures and not how they work, that a lack of cost control may be a serious risk in developing social health insurance and that it is important to have clear mechanisms for setting priorities if policy goals are to be met.
Cost Allocation↗
A systematic review of the role of human papillomavirus testing within a cervical screening programme.
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Female↗
Can an economic case be made for investing in health?. No, but it's the wrong question.
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Cost-Benefit Analysis↗
Children's construction of a deceased parent: the surviving parent's contribution.
Constructing a connection to the deceased is helpful to children in adjusting to the death of a parent. Using interview data from a subset of a larger study of childhood bereavement, this paper describes ways in which parents help children, ages 10-12, build this connection, provides case examples contrasting parental attitudes and behavior that are helpful and those that are not helpful to the child, and offers implications for clinical practice.
Adaptation, Psychological↗
Ten popular health economic fallacies.
Important decisions about the financing, determining priorities in and provision of health services depend on beliefs about facts and relationships. It is argued in this paper that many popular beliefs are either logically wrong or are not supported by the evidence. Important errors exist in the beliefs about the effects of technology and ageing populations on health care costs, affordability of care, capital resources, financing mechanisms, efficiency and economies of scale, the growth of litigation, priority setting and the importance of getting people back to work. This paper aims to correct some of these fallacies and suggest alternative beliefs that better match the theory or fit the evidence.
Attitude to Health↗
Costing model for neonatal screening and diagnosis of haemoglobinopathies.
AIM: To compare the costs and cost effectiveness of universal and targeted screening for the haemoglobinopathies; to compare the cost of two laboratory methods; and to estimate the cost effectiveness of programmes at different levels of prevalence and mix of haemoglobinopathy traits. METHODS: A retrospective review of laboratory and follow up records to establish workload and costs, and estimation of costs in a range of circumstances was made in a haematology department and sickle cell and thalassaemia centre, providing antenatal and neonatal screening programmes in Inner London. The costs for 47,948 babies, screened during 1994, of whom 25 had clinically significant haemoglobinopathies and 704 had haemoglobinopathy traits, were retrospectively assessed. RESULTS: The average cost per baby tested (isoelectric focusing and high power liquid chromatography) was 3.51 Pounds /3.83 Pounds respectively; the cost per case of sickle cell disease identified (IEF/HPLC) was 6738 Pounds /7355 Pounds; the cost per trait identified (IEF/HPLC) was 234 Pounds /255 Pounds; the cost per extra case of SCD and trait identified by universal programme varied. CONCLUSIONS: IEF and HPLC are very similar in terms of average cost per test. At 16 traits/1000 and 0.5 SCD/1000 there was no significant identification cost difference between universal and targeted programmes. Below this prevalence, a targeted programme is cheaper but likely to miss cases of SCD. If targeted programmes were 90-99% effective, universal programmes would cease to be good value except at very high prevalence. Greater use of prenatal diagnosis, resulting in termination, and therefore fewer affected births, reduces the cost effectiveness of universal screening. Screening services should aim to cover a screened population which will generate a workload over 25,000 births a year, and preferably over 40,000.
Chromatography, High Pressure Liquid↗
Putting trials on trial--the costs and consequences of small trials in depression: a systematic review of methodology.
STUDY OBJECTIVE: To determine why, despite 122 randomised controlled trials, there is no consensus about whether the selective serotonin reuptake inhibitors or tricyclic and related antidepressants should be used as first line treatment of depression. DESIGN: Systematic review of all RCTs comparing selective serotonin reuptake inhibitors and tricyclic or heterocyclic antidepressants. MAIN RESULTS: The shortcomings identified in the 122 trials were as follows: (1) there was inadequate description of randomisation, (2) the outcomes used were mainly observer rated measurements of depression, and studies failed to use quality of life measures or perform economic evaluations, (3) doses of tricyclic antidepressants were inadequate, (4) generalisability of studies was poor (including a reliance on secondary care settings and inadequate follow up), and (5) there were statistical shortcomings such as low statistical power, failure to use intention to treat analyses, and the tendency to make multiple comparisons. CONCLUSIONS: Future RCTs should be designed to inform policy makers and address these methodological shortcomings.
Antidepressive Agents, Tricyclic↗
The cardiac waiting game: are patients prioritized on the basis of clinical need?
Waiting lists for coronary artery bypass grafting (CABG) have been a recurring problem for many hospitals, putting pressure on hospitals to manage waiting lists more effectively. In this study, we audited the records of 1594 patients who had coronary artery bypass surgery in 1992 and 1993 in three London hospitals, to assess their waiting time experience. Patients' actual waiting times were compared with an appropriate waiting time defined using an adapted version of a Canadian urgency scoring system. Influence of other factors (sex, age, smoking, hypertension, diabetes and obesity) on actual waiting time was assessed. A comparison of patients' actual waiting times with an appropriate waiting time, defined by the urgency score, showed that only 38% were treated within the appropriate period. Thirty-four per cent were treated earlier than their ischaemic risk indicated, and 28% with high ischaemic risk were delayed. Actual waiting time was associated with a patient's sex and smoking status but not with the other factors studied. The current system of prioritizing patients awaiting CABG is not concordant with a measure of appropriate waiting time. This could have arisen due to a number of factors, including the contracting process, waiting list initiatives, and methods of waiting list administration and patient pressures. The use of a standard method for prioritizing patients would enable a more appropriate use of resources.
Cardiology Service, Hospital↗
Costs and cost effectiveness of health checks conducted by nurses in primary care: the Oxcheck study.
OBJECTIVE: To measure the costs and cost effectiveness of the Oxcheck cardiovascular risk factor screening and intervention programme. DESIGN: Cost effectiveness analysis of a randomised controlled trial using clinical and economic data taken from the trial. SETTING: Five general practices in Luton and Dunstable, England. SUBJECTS: 2205 patients who attended a health check in 1989-90 and were scheduled for re-examination in 1992-3 (intervention group); 1916 patients who attended their initial health check in 1992-3 (control group). Participants were men and women aged 35-64 years. INTERVENTION: Health check conducted by nurse, with health education and follow up according to degree of risk. MAIN OUTCOME MEASURES: Cost of health check programme; cost per 1% reduction in coronary risk. RESULTS: Health check and follow up cost 29.27 pounds per patient. Estimated programme cost per 1% reduction in coronary risk per participant was between 1.46 pounds and 2.25 pounds; it was nearly twice as much for men as women. CONCLUSIONS: The cost to the practice of implementing Oxcheck-style health checks in an average sized practice of 7500 patients would be 47,000 pounds, a proportion of which could be paid for through staff pay reimbursements and Band Three health promotion target payments. This study highlights the considerable difficulties faced when calculating the costs and benefits of a health promotion programme. Economic evaluations should be integrated into the protocols of randomised controlled trials to enable judgments to be made on the relative cost effectiveness of different prevention strategies.
Adult↗
What can be concluded from the Oxcheck and British family heart studies: commentary on cost effectiveness analyses.
OBJECTIVES: To provide a commentary on the economic evaluations of the Oxcheck and British family heart studies: direct comparison of their relative effectiveness and cost effectiveness; comparisons with other interventions; and consideration of problems encountered. DESIGN: Modelling from cost and effectiveness data to estimate of cost per life year gained. SUBJECTS: Middle aged men and women. INTERVENTIONS: Screening for cardiovascular risk factors followed by appropriate lifestyle advice and drug intervention in general practice, and other primary coronary risk management strategies. MAIN OUTCOME MEASURES: Life years gained; cost per life year gained. RESULTS: Depending on the assumed duration of risk reduction, the programme cost per discounted life year gained ranged from 34,800 pounds for a 1 year duration to 1500 pounds for 20 years for the British family heart study and from 29,300 pounds to 900 pounds for Oxcheck. These figures exclude broader net clinical and cost effects and longer term clinical and cost effects other than coronary mortality. CONCLUSIONS: Despite differences in underlying methods, the estimates in the two economic analyses of the studies can be directly compared. Neither study was large enough to provide precise estimates of the overall net cost. Modelling to cost per life year gained provides more readily interpretable measures. These estimates emphasise the importance of the relatively weak evidence on duration effect. Only if the effect lasts at least five years is the Oxcheck programme likely to be cost effective. The effect must last for about 10 years to justify the extra cost associated with the British family heart study.
Adult↗
The costs of nursing turnover: evidence from the British National Health Service.
This article reports empirical evidence on the costs of nursing and other staff turnover in the National Health Service. It begins by considering the possible costs and benefits associated with turnover. It then examines current turnover rates in the NHS and existing estimates of the direct administrative costs and the short-term productivity losses associated with turnover. Using these estimates, it compares the cost-effectiveness of a policy which uses across-the-board pay increases to reduce turnover with one which targets pay rises to certain groups only. Next, possible indirect costs of turnover are evaluated using data collected from a large cross-section of providers and other sources. No relationship is found between turnover rates and crude measures of patient service or staff morale measures. The paper concludes with a brief discussion of the main findings and some suggestions for future research.
Cost-Benefit Analysis↗
A cost-effectiveness analysis of neonatal ECMO using existing evidence.
A cost-effectiveness analysis is part of the U.K. ECMO Trial. In preparation for this analysis, existing evidence on the costs and effectiveness of neonatal ECMO was evaluated. ECMO appears to be more costly but may be more or less effective than conventional treatment. No case can be made for introducing ECMO before trial results are available.
Cost-Benefit Analysis↗
A comparison of three measures of perceived distress: results from a study of angina patients in general practice in Northern Ireland.
OBJECTIVE: To establish the effect of health education on the level of distress felt by patients with angina and to compare the results obtained using different measures. DESIGN: Randomised controlled trial of personal health education given every four months. SETTING: Eighteen general practices in the greater Belfast area. SUBJECTS: These comprised 688 patients aged less than 75 years and known to have had angina for at least six months: 342 were randomised to receive education and 346 no education. MAIN OUTCOME MEASURES: These were the Nottingham health profile (NHP), functional limitation profile (FLP), and a simple categorical scale (SCS). RESULTS: The intervention group showed a statistically significant improvement in health relative to the control group in terms of physical mobility and social isolation using the NHP. In terms of overall wellbeing, both the NHP and SCS results showed the intervention group had experienced statistically significant improvements in health relative to the control group. Results obtained using the NHP, FLP, and SCS were found to be correlated regardless of whether weighted or unweighted scores were used. CONCLUSION: The intervention produced a significant improvement in health status. Results from different survey instruments were correlated using both weighted and unweighted scores. An SCS was capable of detecting the improvement in health status.
Aged↗
Cost effectiveness of personal health education in primary care for people with angina in the greater Belfast area of Northern Ireland.
STUDY OBJECTIVE: To investigate the cost effectiveness of personal health education for angina patients being treated in general practice. DESIGN: A randomised controlled trial in which people were randomised to intervention and control groups. All were assessed at the start and end of the study, with details recorded of disease status, coronary heart disease risk factors, and self assessed quality of life. A note was taken of their current use of drugs and over the course of the study their use of all health services. Those in the intervention group had three visits per year from a health visitor, whose brief was discuss ways of living more easily with their disease and in which risks of further events might be reduced. PATIENTS: Altogether 688 patents in the Greater Belfast area aged less than 75 years and known to have angina for at least six months. MAIN RESULTS: Significant improvements in survival and self assessed quality of life were found between the study and control groups. The intervention was associated with a reduction in drug usage and there was no significant difference between the intervention and control groups in terms of their use of other health services. CONCLUSION: Given the improvement in survival and self assessed quality of life and no significant differences in costs to the health service between the two groups, the intervention was deemed to be cost effective.
Angina Pectoris↗
Economics and evaluation of palliative care.
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Cost-Benefit Analysis↗
Are SSRIs a cost-effective alternative to tricyclics?
BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) are more expensive than tricyclics. Reports have suggested that SSRIs are cost-effective because they are better tolerated and safer in overdose. METHOD: A systematic review of all randomised controlled trials (RCTs), meta-analyses, and cost-effectiveness studies comparing SSRIs and tricyclic antidepressants (TCAs). RESULTS: None of the RCTs provided an economic analysis and there were methodological problems in the majority which would preclude this approach. Meta-analyses suggest that clinical efficacy is equivalent but slightly fewer patients prescribed SSRIs drop out of RCTs. Cost-effectiveness studies have been based on crude 'modelling' approaches and over-estimate the difference in attrition rates and the cost of treatment failure. It appears impossible to evaluate the economic aspects of suicide because of its rarity. CONCLUSIONS: There is no evidence to suggest that SSRIs are more cost-effective than TCAs. The debate will only be concluded when a prospective cost-effectiveness study is done in the setting of a large primary care based RCT.
Antidepressive Agents, Tricyclic↗
Strategies for reducing coronary risk factors in primary care: which is most cost effective?
OBJECTIVE: To examine the relative cost effectiveness of a range of screening and intervention strategies for preventing coronary heart disease in primary care. SUBJECTS: 7840 patients aged 35-64 years who were participants in a trial of modifying coronary heart disease risk factors in primary care. DESIGN: Effectiveness of interventions assumed and the potential years of life gained estimated from a risk equation calculated from Framingham study data. MAIN OUTCOME MEASURE: The cost per year of life gained. RESULTS: The most cost effective strategy was minimal screening of blood pressure and personal history of vascular disease, which cost 310 pounds-930 pounds per year of life gained for men and 1100 pounds-3460 pounds for women excluding treatment of raised blood pressure. The extra cost per life year gained by adding smoking history to the screening was 400 pounds-6300 pounds in men. All strategies were more cost effective in men than in women and more cost effective in older age groups. Lipid lowering drugs accounted for at least 70% of the estimated costs of all strategies. Cost effectiveness was greatest when drug treatment was limited to those with cholesterol concentrations above 9.5 mmol/l. CONCLUSIONS: Universal screening and intervention strategies are an inefficient approach to reducing the coronary heart disease burden. A basic strategy for screening and intervention, targeted at older men with raised blood pressure and limiting the use of cholesterol lowering drugs to those with very high cholesterol concentrations would be most cost effective.
Adult↗