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Biomedical subjects

D K Whynes

Publications and source records attributed to D K Whynes.

At least 55 records · Page 3Linked to original sources
PubMed1996

The costs of prescribing in dispensing practices.

The existence of significant disparities between the prescribing costs of dispensing and non-dispensing general practices has long been suspected, and received confirmation in a study of Lincolnshire, based on data for 1990-91. This study subsequently attracted much criticism. In this paper, we extend the analysis by considering annual cost and other prescribing data for Lincolnshire for the years between and including 1990-91 and 1993-94, in the light of the prescribing criteria developed by the Audit Commission. Our results show that dispensing practices had higher prescribing costs per patient for all the years analysed. In 1993-94, dispensing practices prescribed more items per patient (fewer of them generically) and were less capable of remaining within their prescribing budgets. The essential difference in prescribing costs lies in the area defined by the Audit Commission as 'core prescribing'. Using the Audit Commission's criteria for 'rational' prescribing, dispensing practices could make a significantly higher level of savings than non-dispensing practices. The findings lend support to the hypothesis advanced in the earlier analysis, namely, that the higher costs of prescribing in dispensing practices are accounted for primarily by management practice and the structure of incentives.

Drug Costs↗
PubMed1995

Optimal times of transfer between therapies: a mathematical framework.

This paper develops a mathematical framework for identifying optimal transfer times from a low-intensity, watchful waiting therapy to direct intervention. It allows for the probability that patients discharged from watchful waiting will suffer disease recurrence. Two specific functional forms for the resolution of the relevant medical condition are modeled (modified exponential and logistic). Initially structured as an expected cost minimisation problem, the analysis is extended to include the possibilities of differential benefits of the therapies and discounted cost and benefit valuations. The framework demonstrates the existence of non-synchronous transfer optima.

Continuity of Patient Care↗
PubMed1995

Determinants of persistent compliance with screening for colorectal cancer.

Mass population screening for colorectal cancer is currently being evaluated by means of randomized controlled trials. These trials point to the likelihood that, if implemented, the level of both initial and sustained compliance will prevent the full potential of screening being realised. The paper opens by reviewing the evidence on determinants of compliance, both initial and longer term, although little empirical evidence on adherence to repeated screening is currently available. The paper then presents the results of a survey of persistent compliers and non-compliers within the English screening trial, in order to identify those characteristics most closely associated with persistent compliance behaviour. Persistent compliers are found, inter alia, to be of higher socio-economic classes than persistent non-compliers, to have more personal and family experiences of illness and to visit their dentists more regularly. The results suggest that generalized attempts at compliance enhancement would be ineffectual against the prevailing background characteristics of the non-compliant population, and that the more overt targeting of efforts in this respect is to be preferred.

Aged↗
PubMed1995

Is an immunological faecal occult blood test better than Haemoccult? A cost-benefit study.

Immunological faecal occult blood (FOB) tests have theoretical advantages over their guaiac counterparts in that they are specific for human haemoglobin. HemeSelect is a semi-quantitative immunological FOB text. Faecal material is eluted into test diluent and serial dilutions are performed. The manufacturers recommend that erythrocyte agglutination at 1:8 dilution is considered a positive reaction. However, further serial dilutions can be carried out and the highest dilution at which the test remains positive determined. At 1:8 dilution, the test has been shown to be more sensitive for symptomatic colorectal cancer than Haemoccult. The aim of this study is to compare the positive rates, neoplastic yield and costs of Haemoccult with HemeSelect at various dilutions in asymptomatic average risk subjects aged 50-74. 1489 subjects satisfactorily completed both tests, 145 (9.7%) returned positive Hemeselect tests (read at 1:8 dilution, 38 patients with neoplasms > or = 1 cm) and 17 positive Haemoccult tests (1.1%). All positive Hemeselect tests were further serially diluted. As the Hemeselect dilution increased to 1:16, 1:32, 1:64 and 1:128 so the positive rate and yields of neoplasms > or = 1 cm progressively fell to 6.8% & 35, 3.6% & 20, 2.7% & 18 and 1.5% & 12, compared with 1.1% and eight neoplasms > or = 1 cm for Haemoccult. In spite of the unit cost of the Hemeselect test being greater than Haemoccult, the cost per neoplasm > or = 1 cm was lower for Hemeselect at 1:8 and 1:16 dilutions than Haemoccult. However, for an equivalent neoplastic yield, Haemoccult was cheaper. Hemeselect is a versatile test whose positive rate can be tailored according to the risk of the group being screened.

Aged↗
PubMed1995

Potential for cost economies in guiding therapy in patients with metastatic breast cancer.

Therapeutic response in patients with advanced breast cancer is conventionally assessed with reference to criteria devised by the International Union Against Cancer. Evidence to date suggests, however, that assessments of equivalent quality may be obtained at lower cost from the use of serum markers. The paper presents estimates of potential cost savings resulting from the use of serum markers in place of conventional assessment and argues that the size of these savings merits the establishment of a randomised controlled trial.

Biomarkers, Tumor↗
PubMed1995

Importance-performance analysis as a guide for hospitals in improving their provision of services.

As a result of the 1990 National Health Services Act, hospitals now compete with one another to win service contracts. A high level of service quality represents an important ingredient of a successful competitive strategy, yet, in general, hospitals have little external information on which to base quality decisions. Specifically, in their efforts to win contracts from fundholding general practitioners, hospitals require information on that which these purchasers deem important with respect to quality, and on how these purchasers assess the quality of their current service performance. The problem is complicated by the fact that hospital service quality, in itself, is multi-dimensional. In other areas of economic activity, the information problem has been resolved by importance-performance analysis and this paper reports the findings of such an analysis conducted for hosptials in the Trent region. The importance and performance service quality ratings of fundholders were obtained from a questionnaire survey and used in a particular variant of importance-performance analysis, which possesses certain advantages over more conventional approaches. In addition to providing empirical data on the determinants of service quality, as perceived by the purchasers of hospital services, this paper demonstrates how such information can be successfully employed in a quality enhancement strategy.

Contract Services↗
PubMed1995

Effect of retesting with dietary restriction in Haemoccult screening for colorectal cancer.

OBJECTIVES: To determine the detection rate, false positive and false negative rates associated with a policy of retesting with dietary restriction after an initial positive Haemoccult screening test for colorectal cancer, in order to compare the cost effectiveness of such a policy with the alternative, in which all subjects with a positive test would proceed directly to diagnostic colonoscopy. METHODS: Over four years in a large randomised control trial in Nottingham 35,260 subjects had a mean of 1.5 screening rounds each at two-yearly intervals, and were followed up for a minimum of 27 months. During this period subjects with positive screening tests were asked to repeat the test with dietary restrictions. Estimates of costs of the initial screening and of diagnostic colonoscopy were used to estimate the cost for each cancer detected by the different policies. RESULTS: 1209 subjects had a positive initial screening test and 1033 (85.4%) completed the retests. Four hundred and ninety nine subjects were investigated and 89 cancers detected. In the 710 subjects with negative retests six interval cancers were diagnosed in the two years after screening. If these had been detected by screening under a policy of immediate colonoscopy, test sensitivity would have been improved from 53.6% to 57.2% (P = 0.02), but the cost for each cancer detected would have increased from pound 773 to pound 1509. CONCLUSION: Retesting with dietary restrictions reduces costs and maximises the benefit of limited colonoscopy resources, but results in a small but significant reduction in test sensitivity compared with a policy for immediate colonoscopy.

Colonoscopy↗
PubMed1994

Colorectal cancer screening and quality of life.

To evaluate the quality of life of patients following surgery for colorectal cancer, and to compare the quality of life between patients whose cancer was detected as a result of faecal occult blood screening with that of patients whose cancer presented symptomatically, an analysis was conducted within the context of the randomized controlled trial of colorectal cancer screening, University Hospital, Nottingham, UK. A total of 418 survivors of the trial's test and control groups and 33 randomly selected cancer patients completed quality of life questionnaires (Nottingham Health Profile and Health Measurement Questionnaire). The mode of entry to diagnosis and treatment (screening vs. non-screening) appeared to exert no major impact on post-intervention quality of life. The stage of cancer progression was not closely related to outcome life quality. A quality of life coefficient for surviving patients based on the Rosser classification was estimated to lie within the range 0.948-0.981. This figure accords well with the estimates of other studies of interventions in populations of similar age. Overall, there are no grounds for believing that faecal occult blood screening for colorectal cancer per se significantly influences patients' post-intervention quality of life.

Aged↗
PubMed1994

Fundholders' referral patterns and perceptions of service quality in hospital provision of elective general surgery.

BACKGROUND: The introduction of fundholding established an internal market in public sector health care, involving purchasers and providers contracting for the supply of health care. AIM: This study set out to examine fundholders' hospital referral patterns, and to evaluate the quality of the service provided to patients undergoing elective general surgery, as perceived by fundholding general practitioners. METHOD: A questionnaire was posted to the senior partners of all fundholding practices in the Trent Regional Health Authority area. This questionnaire requested assessments of the importance of 13 specified aspects of service quality and the quality of provision by general practitioners' most frequently-used hospitals. Five-point scales were employed in each case. Respondents were asked to provide additional details about their practice. RESULTS: A 67% response rate was achieved. Confidence in the consultant's ability, short waiting times and informative feedback from the providers emerged as the most important elements in referral decisions, while the cost of treatment and patient convenience received lower importance ratings. In terms of how well their providers were seen to perform, fundholders ranked confidence in the consultant and patient convenience highest, and style of hospital management lowest. The majority of referrals seemed to be local. CONCLUSION: Judged in terms of fundholders' perceptions, sizeable variations in service quality between hospital providers of general surgery are evident.

Elective Surgical Procedures↗
PubMed1993

Prevention of colorectal cancer by once-only sigmoidoscopy.

There is no national screening programme for colorectal cancer in the UK despite the fact that the annual death toll from this disease exceeds that of breast and cervical cancer. Faecal occult blood testing (FOBT) is under evaluation for screening, but screening by sigmoidoscopy is not considered viable. This situation contrasts with the USA where both annual FOBT and screening by flexible sigmoidoscopy every 3 to 5 years are recommended from 50 years old. We seek to demonstrate that most of the benefit from the US screening policy would accrue from a single flexible sigmoidoscopy examination at age 55 to 60 years with appropriate colonoscopic surveillance for the 3% to 5% found to have high-risk adenomas (> or = 1 cm or villous histology). If applied nationally, this screening regimen could prevent about 5500 colorectal cancer cases and 3500 deaths in the UK each year, thus saving 40,000 years of life. We estimate that there would be little net cost to the National Health Service because savings obtained from treating fewer patients would largely offset the cost of screening. We recommend that a randomised trial to evaluate screening by single flexible sigmoidoscopy should start without delay. Such a trial would involve about 120,000 participants, and 15 years of follow-up would be required to obtain a clear answer on mortality, although information on incidence reduction would be available sooner.

Adult↗
PubMed1993

Convergent validity of two measures of the quality of life.

In the paper, a test of convergent validity is undertaken for two methods of quality of life assessment, one based on a shortened version of the Health Measurement Questionnaire and the other based on professional clinical judgement. The Nottingham Health Profile is used as the comparator, and the data derive from a sample of colorectal cancer patients. Criteria for convergent validity are established and both methods yield outcomes broadly consistent with such criteria.

Activities of Daily Living↗
PubMed1993

Screening and the costs of treating colorectal cancer.

The objective of this paper is to compare the hospital costs of treating patients with colorectal cancers detected as a result of a faecal occult blood screening programme with those of patients whose cancers present symptomatically (control group). Patient-specific cost estimates are made, using case records and hospital accounts, for 360 patients over 3 years. Mean treatment costs for the group offered screening and for the control group are calculated to be 3,179 pounds and 2,966 pounds respectively, although the difference between these means is insignificant. Low treatment costs in the case of screen-detected cancers are largely accounted for by polypectomy with no subsequent readmission; in the control group case, they tend to be accounted for by early patient death. For the sample as a whole, the costs of treating very early-, and very late-, stage cancer are significantly lower than those of treating cancers in the intermediate stages. On the basis of trial evidence, the introduction of mass screening for colorectal cancer is unlikely to give rise to substantial economies in the costs of treatment.

Colorectal Neoplasms↗
PubMed1992

Cost savings in mass population screening for colorectal cancer resulting from the early detection and excision of adenomas.

The widely-accepted hypothesis of a development sequence from colorectal adenoma to carcinoma is felt by clinicians to legitimate adenoma excision during routine colonoscopic investigation. Using published data on adenoma development, and adenoma prevalence data derived from the Nottingham colorectal cancer screening trial, the number of carcinomas prevented by early excision as a result of screening is predicted. The cost-effectiveness of early excision is then evaluated with reference to the expected treatment costs saved. These cost savings are found to represent a discount on the overall costs of mass population screening for colorectal cancer.

Adenoma↗
PubMed1992

The health of the Nottingham homeless.

This paper presents the findings of a survey of approximately 2,000 homeless individuals applying for shelter to statutory and voluntary sector agencies in Nottingham. The socio-demographic and economic characteristics of the sample are described, and are analysed in relation to reported health problems. The incidence of reported health problems amongst these homeless individuals is compared with that reported in the 1988 General Household Survey (GHS). Whilst the shelter applicants are reporting fewer health problems than the GHS population, because they are a considerably younger and thus healthier sample, subsets of the homeless with specific characteristics do indeed provide evidence of a disproportionate incidence of ill health.

Adolescent↗
PubMed1992

Effect of subject age on costs of screening for colorectal cancer.

STUDY OBJECTIVE: The aim was to estimate costs and yields of faecal occult blood screening and rescreening for colorectal cancer, for differing age cohorts. DESIGN: Cost and clinical data were used as the basis for modelling the expected costs, and cost savings, resulting from the treatment of screen detected cancers, as compared with cancers detected by symptomatic presentation. SETTING: Data were derived from the MRC screening trial currently in progress in Nottingham. PARTICIPANTS: Approximately 140,000 subjects, age 50-79 years, were randomly allocated to a test (screened) and a control (unscreened) group. MAIN RESULTS: The net costs of detecting and treating a cancer following colorectal screening fall as the age of the target population increases, owing principally to the increasing incidence of the disease with age. Generally, the marginal detection and treatment costs falls for all age groups with the first screening round, but rises considerably with the second. If allowance is made for cancers prevented as a result of early detection and excision of adenomas, the costs of screening are substantially reduced for all age groups. CONCLUSIONS: Assuming a cost per QALY (quality adjusted life year gained) equivalent to that derived for the breast cancer screening programme, and a QALY gain from colorectal screening of one year, three screens, each separated by two years, appear economically justified for populations aged 60 years and above. Expected gains from cancer prevention make two screens justifiable for those between 45 and 59 years of age.

Age Factors↗
PubMed1992

Cost-effective screening strategies for colorectal cancer.

This paper models a range of feasible strategies for mass population screening for colorectal cancer. It uses both clinical and economic data derived from the major colorectal cancer screening trial currently under way in Nottingham, supplemented by data from concurrent Scandinavian trials. Costs and yields for 12 strategies are modelled, and optima are identified according to a number of evaluation criteria. The cost-effectiveness condition for the desirability of introducing a programme of colorectal screening is also established.

Aged↗
PubMed1991

Participation and screening programmes for colorectal cancer: more would be better?

In clinical terms, a screening compliance rate of 100% may be deemed optimal in that the number of abnormalities detected is thereby maximized. This paper explores optimum compliance rates from the cost-effectiveness point of view by modelling the individual's decision to participate in the screening programme. Using data derived from contemporary colorectal screening trials, it assesses the compliance and cost effects of utilizing differing methods of screening invitation, and explores the incremental cost and benefits associated with compliance enhancement techniques. Given the estimated costs and benefits, attempts to attain higher levels of compliance would appear justifiable.

Attitude to Health↗