Search PubMed⌕ Search

Biomedical subjects

J E Brazier

Publications and source records attributed to J E Brazier.

At least 19 recordsLinked to original sources
PubMed2006

Cost-effectiveness analysis of surgery versus conservative treatment for uncomplicated varicose veins in a randomized clinical trial.

BACKGROUND: Despite being a common procedure, the cost effectiveness of surgery for varicose veins has not been established. METHODS: Cost-effectiveness analysis was carried out alongside a randomized clinical trial at two vascular units within National Health Service (NHS) hospitals. Some 246 patients with uncomplicated varicose veins and evidence of saphenofemoral or saphenopopliteal reflux were allocated randomly to receive either conservative management or surgical treatment. Incremental cost per quality-adjusted life year (QALY) gained at 24 months following randomization was calculated. RESULTS: Total NHS costs during the 2-year study period were higher for the surgically treated group (733 UK pounds) than for those who had conservative treatment (345 UK pounds). The difference in costs was statistically significant. The mean incremental health gain from surgical treatment at 24 months was 0.083 QALYs, leading to a base-case estimate of 4682 UK pounds per QALY gained. Assuming an implicit threshold maximum willingness-to-pay value of 20 000 UK pounds for a QALY, the probability of surgical treatment for varicose veins falling below this threshold value was 70 per cent. This result was found to be robust to sensitivity analysis. CONCLUSION: For patients with uncomplicated varicose veins and evidence of saphenofemoral or saphenopopliteal reflux, surgical treatment for varicose veins offers a modest health benefit for relatively little additional NHS cost relative to conservative treatment.

Cost-Benefit Analysis↗
PubMed2006

Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins.

BACKGROUND: Surgical treatment of medically uncomplicated varicose veins is common, but its clinical effectiveness remains uncertain. METHODS: A randomized clinical trial was carried out at two large acute National Health Service hospitals in different parts of the UK (Sheffield and Exeter). Some 246 patients were recruited from 536 consecutive referrals to vascular outpatient clinics with uncomplicated varicose veins suitable for surgical treatment. Conservative management, consisting of lifestyle advice, was compared with surgical treatment (flush ligation of sites of reflux, stripping of the long saphenous vein and multiple phlebectomies, as appropriate). Changes in health status were measured using the Short Form (SF) 6D and EuroQol (EQ) 5D, quality of life instruments based on SF-36 and EuroQol, complications of treatment, symptomatic measures, anatomical extent of varicose veins and patient satisfaction. RESULTS: In the first 2 years after treatment there was a significant quality of life benefit for surgery of 0.083 (95 per cent confidence interval (c.i.) 0.005 to 0.16) quality-adjusted life years (QALYs) based on the SF-6D score and 0.13 (95 per cent c.i. 0.016 to 0.25) based on the EQ-5D score. Significant benefits were also seen in symptomatic and anatomical measures. CONCLUSION: Surgical treatment provides symptomatic relief and significant improvements in quality of life in patients referred to secondary care with uncomplicated varicose veins.

Exercise Therapy↗
PubMed2006

Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial).

OBJECTIVES: To establish the cost-effectiveness of surgery and sclerotherapy for the treatment of varicose veins. DESIGN: Randomised controlled trials (RCTs) were carried out for conservative treatment, sclerotherapy and surgery for varicose veins. An economic analysis was carried out alongside the randomised trial. Economic modelling was undertaken based on the primary data collection and a literature review (database searches undertaken in April 2000 and updated in March 2001). SETTING: Primary data collection was from a large district general hospital and a teaching hospital both in England over a 2-year period from January 1999. Cost-effectiveness analysis and economic modelling were carried out using an NHS perspective. PARTICIPANTS: A total of 1009 patients were recruited. INTERVENTIONS: Thirty-four patents were randomised in Group 1 (minor varicose veins with no reflux, randomised between conservative treatment and sclerotherapy), 77 in Group 2 (moderate varicose veins with reflux, randomised between surgery and sclerotherapy) and 246 in Group 3 (severe varicose veins with reflux, randomised between conservative treatment and surgery). The remaining 652 patients formed the observational part of the study. MAIN OUTCOME MEASURES: The cost-effectiveness analysis was based on NHS treatment costs for the 2002--3 financial year, and utilities based on the Short Form 6D (SF-6D) preference-based health measure. For the clinical trial, the outcome measures were health-related quality of life (HRQoL) [Short Form with 36 Items (SF-36), EuroQol quality of life questionnaire (EQ-5D), visual analogue scale (VAS) and standard gamble], symptomatic relief, anatomical extent (for which a new classification was developed and validated), patient satisfaction and the incidence of complications. RESULTS: Of the RCTs, only the Group 3 trial was large enough to provide clear results. This showed that surgical treatment produced better results than conservative treatment in terms of HRQoL, symptomatic relief, anatomical extent and patient satisfaction. Clinical outcomes of surgery and sclerotherapy showed significant improvement in the extent of varicose veins, symptomatic and HRQoL parameters. Cost-effectiveness analysis based on the Group 3 trial showed that the surgery produced an estimated discounted benefit of 0.054 quality-adjusted life-year (QALY) over a 2-year period, with an additional discounted cost of pound 387.45, giving an incremental cost-effectiveness ratio (ICER) of pound 7175 per QALY. Economic modelling suggested that surgery produced a still greater benefit when considered with a 10-year time horizon, with an ICER of pound 1936 per QALY. Injection sclerotherapy produced an incremental benefit of approximately 0.044 QALY at a cost of pound 155 when compared with conservative treatment, giving an ICER of pound 3500 per QALY. When surgery was compared with sclerotherapy, surgery produced greater benefit with a lower ICER (showing extended dominance). CONCLUSIONS: Standard surgical treatment of varicose veins by saphenofemoral ligation, stripping and multiple phlebectomies is a clinically effective and cost-effective treatment for varicose veins, with an ICER well below the threshold normally considered appropriate for the funding of treatments within the NHS. Injection sclerotherapy also appears to be cost-effective, but produces less overall benefit, with a higher ICER than surgery for patients with superficial venous reflux. In minor varicose veins without reflux, sclerotherapy is likely to provide a small average benefit with acceptable cost-effectiveness. Research is needed into methods for accurate and acceptable utility evaluations for conditions with relatively minor effect on HRQoL and also for a validated and standardised method of classification for varicose veins.

Adolescent↗
PubMed2005

The development of a preference-based measure of health in children with atopic dermatitis.

BACKGROUND: Outcomes of health care interventions can be measured in many different ways, but there has been growing interest in the role that quality-adjusted life-years (QALYs) can play in informing priorities in health care. While existing generic preference-based measures can be used to obtain QALYs, these measures may often be inappropriate for some conditions such as atopic dermatitis (AD). These measures are also usually developed for adults and may not capture the domains pertinent to children. OBJECTIVES: To develop a preference-based quality-of-life measure for use in children with AD. METHODS: Items generated from interviews conducted with parents of children with AD were used to form a health state classification system that gives 16 unique health states. One hundred and fifty members of the general population were interviewed to derive preference weights for these states, following the methods used in the valuation of the Health Utilities Index 2 (HUI 2). Each person valued 10 health states using the standard gamble technique. The primary analysis was the estimation of mean health state values for each of the 16 states. RESULTS: Mean values across the 16 health states range from 0.36 (SD = 0.36) for the worst state to 0.84 (SD = 0.19) on a scale from zero to one, where zero is for health states thought to be as bad as being dead and one is for perfect health. There was some support for the validity of the values from the fact that the values were logically consistent with the ordering of the health state classification system. CONCLUSIONS: These results show the perceived importance of the defined health states of childhood AD to the general population. The resultant health state classification and values can be used to calculate QALYs for use in assessing the cost-effectiveness of interventions for children with AD.

Adolescent↗
PubMed2003

Treating dyspepsia with acupuncture and homeopathy: reflections on a pilot study by researchers, practitioners and participants.

OBJECTIVES: For people with dyspepsia who are receiving orthodox general practice care, what is the effect on outcome and on NHS costs of adding treatment by a choice of acupuncture or homeopathy? This paper describes and reflects upon a pilot study with user involvement. DESIGN: A randomised pilot study. Patients chose between acupuncture and homeopathy and were then randomised to this preference or to the control group of normal GP care. SETTING AND PARTICIPANTS: Sixty people with dyspepsia (>/=2 weeks) presenting in one UK general practice were recruited in consultations and by letter to those on repeat prescriptions. There were few exclusion criteria. The homeopath and the acupuncturist treated the patient individually according to their normal practice for up to 6 months. After the trial there was a focus group for participants. OUTCOME MEASURES: SF-36 health survey, Measure Yourself Medical Outcome Profile (MYMOP), and General Well-being Index (GWBI). Counts of prescriptions, consultations and referrals from practice computer records. RESULTS: No trend or significant difference between the groups for clinical outcome or NHS costs. Major costs for the 6 months, mean (S.D.) cost per patient, were general practitioner consultations pound 8 (18), prescriptions pound 64 (73), acupuncture pound 175 (52), homeopathy pound 105 (33). Participants gave insights and suggestions which will inform the full trial design. CONCLUSIONS: Reflection on the pilot study data and experience by participants, treating practitioners and researchers led to modifications in the design and a sample size calculation. How to demonstrate individual responses to treatment remains a problem.

Acupuncture Therapy↗
PubMed2002

A systematic review of health state utility values for osteoporosis-related conditions.

An important weakness of economic models in the field of osteoporosis has been the dependence on assumptions or expert judgements rather than empirical estimates for the utility values of key health events associated with osteoporosis such as hip, vertebral, wrist fracture and established osteoporosis. This paper seeks to identify the best available utility estimates for health states associated with osteoporosis and make recommendations about their use. It is based on a systematic search of the main literature databases. Studies meeting inclusion criteria have been reviewed in terms of the appropriateness of the valuation technique, the validity of the descriptive system (if one was used), the number and type of respondents, and overall quality of the study. Twenty three estimates of health state values (HSVs) were found across the four conditions from five studies. These empirical estimates were found to differ significantly from the commonly used assumptions in economic evaluation, but with a wide variation between estimates for the same state (0.32 to 0.80 for vertebral fracture states). This variation can be partly explained by the valuation technique, health state description and the background and perspective of respondent, and leaves scope for considerable discretion that could be abused. There are also problems in using values obtained from the study populations to those in economic models and the difficulty of predicting health state values in those who avoid a fracture. The review recommends a set of health state values as part of a "reference case" for use in economic models. Due to the paucity of good quality of estimates in this area, further recommendations are made regarding the design of future studies to collect HSVs relevant to economic models.

Aged↗
PubMed2001

Economics of surgery.

The time has come to subject surgery to the same rigours of economic assessment that other health-care sectors are already receiving--namely, the comparative assessment of costs and benefits. The surgical management of gallstones provides a good example of the role of economics in surgery. Gallstone disease is common and patients are usually referred to a surgeon, but the threshold for intervention is not agreed and varies widely, with considerable implications for resources. Gallstone removal has been subject to much innovation over the past 10 years, yet economic assessment of laparoscopic and "mini" cholecystectomy and of gallstone lithotripsy is rare, despite the fact that operation rates have increased by up to 50% in some countries. For surgery to compete with other interventions, economic assessment of new surgical techniques will be increasingly important. This assessment should be based on well-conducted clinical trials in which interventions are provided in a routine service setting, and in which benefits are assessed among other things on the basis of the patient's perceived quality of life. Economic assessment often needs data beyond those collected in a clinical trial, however pragmatic the trial design, so modelling will often be required, incorporating a range of sources of evidence. Finally, evidence alone will not be enough to promote cost-effective practices. The take-up of surgical techniques will always be affected by the way hospitals and surgeons are remunerated. Affecting practice requires a realistic system of reimbursement that reflects evidence on cost effectiveness.

Cholecystectomy, Laparoscopic↗
PubMed2001

Using the SF-36 with older adults: a cross-sectional community-based survey.

OBJECTIVES: To assess the practicality and validity of using the 36-item short-form health survey (SF-36) in a community-dwelling population over 65, and to obtain population scores in this age group. DESIGN: Postal survey, using a questionnaire booklet containing the SF-36 and other health-related items, of all those aged 65 or over registered with 12 general practices in Sheffield. Non-respondents received up to two reminders at 3-weekly intervals. SAMPLE: 9897 subjects, aged 65-104 years. MAIN OUTCOME MEASURES: Scores for the eight dimensions of the SF-36 and a modified version of the physical functioning dimension. RESULTS: The SF-36 achieved a response rate of 82% (n=8117) and dimension completion rates of 86.4-97.7%. Internal consistency measured by Cronbach's alpha exceeded 0.80 for all dimensions except social functioning. These results compare favourably with postal surveys of younger adults. We calculated scores for older adults by age and sex. Comparison with data from younger people showed how physical health declines steeply with age, in marked contrast to mental health. CONCLUSIONS: The SF-36 is a practical and valid instrument for use in postal surveys of older people living at home. The population scores provided here may facilitate its use in future surveys of older adults.

Aged↗
PubMed1999

Generic and condition-specific outcome measures for people with osteoarthritis of the knee.

OBJECTIVES: The aims of this study were to evaluate two condition-specific and two generic health status questionnaires for measuring health-related quality of life in patients with osteoarthritis (OA) of the knee, and to offer guidance to clinicians and researchers in choosing between them. METHODS: Patients were recruited from two settings: 118 from knee surgery waiting lists and 112 from rheumatology clinics. Four self-completion questionnaires [Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Health Assessment Questionnaire (HAQ), Short Form-36 (SF-36) and Euroqol] were sent to subjects on two occasions 6 months apart. Construct validity, convergent validity, internal consistency and responsiveness were examined using primarily non-parametric methods. RESULTS: All instruments proved satisfactory in terms of ease of use, acceptability to patients, internal consistency and reliability. In the surgical group, the OA-specific WOMAC performed better than the HAQ and the generic measures in terms of validity and responsiveness to change, whereas in the rheumatology group the SF-36 was more responsive. CONCLUSION: WOMAC is the instrument of choice for evaluating the outcome of knee replacement surgery in OA. The SF-36 provides a more general insight into patients' health and may be more responsive to change than the WOMAC in a heterogeneous rheumatology clinic population. Researchers wishing to undertake an economic evaluation might consider the EQ-5D for a surgical, but not a rheumatology clinic group.

Aged↗
PubMed1998

Cross-validation of item selection and scoring for the SF-12 Health Survey in nine countries: results from the IQOLA Project. International Quality of Life Assessment.

Data from general population surveys (n = 1483 to 9151) in nine European countries (Denmark, France, Germany, Italy, the Netherlands, Norway, Spain, Sweden, and the United Kingdom) were analyzed to cross-validate the selection of questionnaire items for the SF-12 Health Survey and scoring algorithms for 12-item physical and mental component summary measures. In each country, multiple regression methods were used to select 12 SF-36 items that best reproduced the physical and mental health summary scores for the SF-36 Health Survey. Summary scores then were estimated with 12 items in three ways: using standard (U.S.-derived) SF-12 items and scoring algorithms; standard items and country-specific scoring; and country-specific sets of 12 items and scoring. Replication of the 36-item summary measures by the 12-item summary measures was then evaluated through comparison of mean scores and the strength of product-moment correlations. Product-moment correlations between SF-36 summary measures and SF-12 summary measures (standard and country-specific) were very high, ranging from 0.94-0.96 and 0.94-0.97 for the physical and mental summary measures, respectively. Mean 36-item summary measures and comparable 12-item summary measures were within 0.0 to 1.5 points (median = 0.5 points) in each country and were comparable across age groups. Because of the high degree of correspondence between summary physical and mental health measures estimated using the SF-12 and SF-36, it appears that the SF-12 will prove to be a practical alternative to the SF-36 in these countries, for purposes of large group comparisons in which the focus is on overall physical and mental health outcomes.

Cross-Cultural Comparison↗
PubMed1998

Comparison of Rasch and summated rating scales constructed from SF-36 physical functioning items in seven countries: results from the IQOLA Project. International Quality of Life Assessment.

Rasch models for polytomous items were used to assess the scaling assumptions and compare item response patterns in the 10-item SF-36 physical functioning scale (PF-10) for general population respondents in Denmark, Germany, Italy, the Netherlands, Sweden, the United Kingdom, and the United States. The Rasch model of physical functioning developed in the United States was compared to models for other countries, and each country was compared to a multinational composite. Strong scale congruence across the seven countries was demonstrated; items that varied between countries and from the composite may reflect unique cultural response patterns or differences in translation. Scoring algorithms based on the Rasch model for each country were superior to the current Likert scoring in tests of relative validity (RV) in discriminating among age groups in all countries. In relation to the Likert PF-10 scoring (RV = 1.00), scores estimated using the Rasch rating scale model achieve a median RV of 1.31 (range: 1.01-1.59), while the Rasch partial credit model attained a median RV of 1.44 (range: 1.01-2.23). Rasch models hold good potential for improving health status measures, estimating individual scores when responses to scale items are missing, and equating scores across countries.

Aged↗
PubMed1997

Comparison of outcome measures for patients with chronic obstructive pulmonary disease (COPD) in an outpatient setting.

BACKGROUND: To assist clinicians and researchers in choosing outcome measures for patients with chronic obstructive pulmonary disease attending routine outpatient clinics, a comparative assessment was undertaken of four questionnaires designed to reflect the patients' perception of their physical and emotional health in terms of their feasibility, validity, reliability, and responsiveness to health change. METHODS: Two condition specific questionnaires, the St George's Respiratory Questionnaire (SGRQ) and Guyatt's Chronic Respiratory Questionnaire (CRQ), and two generic questionnaires, the Short Form-36 Health Survey (SF-36) and Euroqol (EQ), were compared for their discriminative and evaluative properties. Spirometric tests and a walking test were also performed. One hundred and fifty six adults who were clinically judged to have COPD and who attended an outpatient chest clinic were assessed at recruitment and six and 12 months later. Patients were also asked whether their health had changed since their last assessment. RESULTS: Completion rates and consistency between items for dimensions of the SGRQ were lower than for dimensions of the other questionnaires. The distributions of responses were skewed for certain dimensions in all questionnaires except the CRQ. Validity was supported for all instruments insofar as patients' scores were associated with differences in disease severity. The generic questionnaires better reflected other health problems. All instruments were reliable over time. The condition specific questionnaires were more responsive between baseline and first follow up visit but this difference did not persist. While certain dimensions of the SF-36 were responsive to patient perceived changes, this did not apply to the derived single index of the EQ. The rating scale of the EQ, however, provided a quick and easy indicator of change. CONCLUSIONS: Evidence from this study supports the CRQ and the SF-36 as comprehensive outcome measures for patients with longstanding COPD.

Aged↗
PubMed1996

Using the SF-36 and Euroqol on an elderly population.

An important methodological issue in measuring health-related quality of life is whether instruments such as SF-36 and EQ can be used on an elderly population. This paper aims to test the completion, reliability and validity of the SF-36 and Euroqol on an elderly female population, and to compare them with the OPCS Disability Survey. Three hundred and eighty women aged 75 and over participated in a randomized controlled trial of the use of clodronate provided the sample. As part of the trial, patients were asked to complete the UK SF-36 and Euroqol, and the OPCS disability survey instrument administered by interview in a hospital clinic at baseline. A random subsample of respondents were retested six months later. The SF-36 achieved poorer levels of completion by dimension (68.1%-88.9%) than the OPCS (99.2%) and Euroqol (84%-93.5%) instruments. There were no major floor effects in the distribution of scores, except for the role dimensions of SF-36. Correlation between test-retest were significant for all instruments, but lower for the role dimensions and social functioning of SF-36, and these dimensions also had 95% Cls for the mean differences in excess of 10 points. There was substantial agreement between the three instruments, and evidence for their construct validity against age and recent use of health services. The sensitivities of the instruments were tested through hypothetical changes in health status. There was some evidence of greater sensitivity to lower levels of morbidity in the SF-36. Where brevity is required and the health changes are expected to be substantial, then EQ may be sufficient. For greater sensitivity SF-36 seems to have an advantage, however lower completion rates and problems with consistency suggest it requires adaptation. One solution would be to use interviewer administration. Another would be to change the SF-36 to make it more suitable for use in elderly people, although this may reduce its usefulness as a generic instrument.

Age Factors↗
PubMed1996

The costs and benefits of helicopter emergency ambulance services in England and Wales.

BACKGROUND: Following the introduction of Helicopter Emergency Ambulance Services (HEAS) in the United Kingdom in the last ten years this paper examines the costs and benefits of three contrasting services in Cornwall, London and Sussex. METHODS: Pre-hospital processes of care were compared between helicopter attended patients and land ambulance patients in all three studies, and health outcomes were compared between helicopter and land ambulance patients in the Cornwall and London studies. A review of the literature on the benefits of HEAS has also been undertaken. RESULTS: There were no improvements in response times and the time on scene was longer for helicopter attended patients. Survival of trauma or cardiac patients attended by helicopter was not improved. In London there was some evidence of worse residual disability in helicopter attended survivors, but in Cornwall residual disability was better in helicopter attended patients. There was no improvement in general health status or aspects of daily living in the helicopter attended patients. The overall total operational costs for these services were [symbol: see text] 55 000 p.a. in Sussex, [symbol: see text] 600 000 in Cornwall and [symbol: see text] 1.2 million in London. CONCLUSION: The analysis suggests that Helicopter Emergency Ambulance Services are costly, the health benefits are small, and there are limited circumstances in which the pre-hospital performance of an ambulance service in England and Wales can be improved.

Adolescent↗
PubMed1996

Measuring the mental health status of a population: a comparison of the GHQ-12 and the SF-36 (MHI-5).

BACKGROUND: A comparison of the performance of the 5-item mental health dimension of SF-36 (MRI-5) with that of the 12-item General Health Questionnaire (GHQ-12) in a defined, non-patient population, using standard statistical tests. METHODS: A postal survey of 3000 patients aged 16-64 years was conducted. Patients were randomly selected from the practice lists of two general practices chosen to represent populations with different socio-economic characteristics. RESULTS: Considerable evidence was found for the internal consistency of both instruments (Cronbach's alpha 0.91 and 0.84 for GHQ-12 and the MHI-5 respectively) and for their construct validity in terms of distinguishing between groups with measured health differences. Both instruments showed a significant difference in the mean scores for men and women. In contrast to the GHQ-12, no correlation was found between age and score for the MHI-5. Both instruments were equally sensitive to socio-economic characteristics and to levels of social support. The scores on the two instruments were highly correlated (Spearman rank correlation-0.73). CONCLUSION: The MHI-5 has comparable psychometric performance to the GHQ-12, and can be used to measure and compare mental health in defined populations. Operational advantages of the MHI-5 over the GHQ-12 are that it is in the public domain, is part of a general health measure (SF-36) and is shorter.

Adolescent↗
PubMed1995

Effects of London helicopter emergency medical service on survival after trauma.

OBJECTIVE: To assess the effect of the London helicopter emergency medical service on survival after trauma. DESIGN: Prospective comparison of outcomes in cohorts of seriously injured patients attended by the helicopter and attended by London ambulance service land ambulances crewed by paramedics. SETTING: Greater London. SUBJECTS: 337 patients attended by helicopter and 466 patients attended by ambulance who sustained traumatic injuries and died, stayed in hospital three or more nights, or had other evidence of severe injury and who were taken to any one of 20 primary receiving hospitals. MAIN OUTCOME MEASURE: Survival at six months after the incident. RESULTS: After differences in the nature and severity of the injuries in the two cohorts were accounted for the estimated survival rates were the same (relative risk of death with helicopter = 1.0; 95% confidence interval 0.7 to 1.4). An analysis with trauma and injury severity scores (TRISS) found 16% more deaths than predicted in the helicopter cohort but only 2% more in the ambulance cohort. There was no evidence of a difference in survival for patients with head injury but a little evidence that patients with major trauma (injury severity score > or = 16) were more likely to survive if attended by the helicopter. An estimated 13 (-5 to 39) extra patients with major trauma could survive each year if attended by the helicopter. CONCLUSION: Any benefit in survival is restricted to patients with very severe injuries and amounts to an estimated one additional survivor of major trauma each month. Over all the helicopter caseload, however, there is no evidence that it improves the chance of survival in trauma.

Adolescent↗