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K Gerard

Publications and source records attributed to K Gerard.

At least 37 records · Page 2Linked to original sources
PubMed1994

Will early detection of breast cancer reduce the costs of treatment?

A substantial investment in resources is required to provide a population-based mammography screening program. At the same time, screening may also reduce the costs of treating breast cancer. Empirical evidence to support such cost savings, however, is limited. This paper presents a simulation of the impact on treatment costs of a population-based mammography screening program in New South Wales. A 1991 cohort of women aged 45 to 69 years is followed for the period 1991 to 2023. With two-yearly screening, the present value of the total health service costs for this cohort would be approximately $112 million. Primary treatment, at $60 million, would cost $5 million more with screening than without. Treatment for advanced stages of the disease would cost $22 million less. Overall, this analysis suggests that savings in treatment costs are relatively small in relation to the overall resource requirements of organised screening.

Aged↗
PubMed1993

QALY league tables: handle with care.

This paper examines some of the difficulties in using QALY league tables in priority setting. Such tables sometimes are seen as being 'the' way to prioritise in health care and in particular, at present, with respect to priority setting among purchasers in the UK NHS. However the paper highlights the fact that the base on which such tables is built is small--relatively few studies in the English language using CUA have been conducted anywhere. Further, four issues which require handling with care are set out: (i) the relevant measure of cost in QALY league tables has to be restricted to health service resource use; (ii) the relevant measure of benefit in QALY league tables is clearly restricted to QALYs, thereby the utility of health gains and indeed the maximisation of the utility of health gains; (iii) in incorporating the results of CUA studies into QALY league tables there is a need for greater clarification on what the margin constitutes; and (iv) those who might use CUA results in QALY league tables need to ascertain whether the original context of the study will allow the results to be transferred to the local context of the decision maker. The paper suggests that there is a need to be quite clear what goal QALY league tables serve. The authors argue that the only legitimate (and clearly important) goal of QALY league tables is the maximization of the utility of health gains within a health service budget.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-Benefit Analysis↗
PubMed1993

Econometric analyses of national health expenditures: can positive economics help to answer normative questions?

The size of national health care expenditure is an important research and policy issue. This paper reviews theoretical and empirical analyses of an implied optimal size for a health sector. Various economic theories are explicitly or implicitly invoked, but none is fully satisfactory. Theory provides, at best, a loose justification for empirical specifications of health sector behaviour. Nevertheless, this has a large and growing empirical research industry. The complexity of the issues provides an excuse for reliance on empirical analyses using ad hoc models. The paper analyses aggregate time-series data, using the cointegration approach, on health, health care expenditures and national income. Only one national model met both statistical criteria and showed a significant relationship: between potential life years lost and health care expenditure in the UK. The case for any general relationships remains unproven. There is no objective scientific method to determine optimal health expenditure, nor should we expect one. However, positive analyses can help with normative questions. A better understanding of health expenditure determination would arise from better specification of the relationships, perhaps by analysis at a lower level of aggregation.

Bias↗
PubMed1993

Setting priorities in the new NHS: can purchasers use cost-utility information?

It could be argued that the success of the new NHS depends, to some extent, on the production of accurate cost-utility information. This raises questions about the quality of this information, whether it can be transferred from one study setting to another and whether such information can reasonably be used 'at the negotiating table'. The quality of some studies is open to question. Some agreement is needed on issues of principle and more work is required to make cost-utility analyses more applicable locally.

Contract Services↗
PubMed1993

Framing and labelling effects in health descriptions: quality adjusted life years for treatment of breast cancer.

At present there is a growing interest in the use of cost-utility analysis (CUA) to a point where it merits serious consideration by health care decision makers. However, there remain a number of theoretical and practical issues to be resolved including the way in which quality of life information is presented and described to subjects. Two potential sources of influence in the construction of the quality adjusted life year (QALY) values elicited for a recent Australian CUA of mammography screening have been investigated. 180 subjects were randomly allocated to nine different presentations of two breast cancer health descriptions to investigate the impact of some framing and labelling effects. No statistically significant differences were found in the valuations placed on these descriptions when framing and labelling effects were taken into account, either as separate framing and labelling factors or as interactions with one another. A significant difference was found in the particular values of descriptions that were written in the third person that differed in terms of whether the word "cancer" was used. The main contribution of these data is to the robustness of the health descriptions used in the cost-utility analysis of mammography screening.

Aged↗
PubMed1993

Community attitudes toward drug use: the need to assess community norms.

Four neighborhoods at high-risk for alcohol and drug problems were surveyed concerning residents' perceptions of the extent and nature of these problems in their neighborhood. Residents were found to have relatively mild perceptions of the extent of misuse but relatively significant experiences with problems caused by drug abuse. They lacked knowledge of treatment and prevention programs. Significant differences were noted among the neighborhoods. Results are discussed in terms of the role of evaluation in community-based programs and the need to survey community norms to plan such programs.

Adult↗
PubMed1992

Cost-utility in practice: a policy maker's guide to the state of the art.

In recent years QALYs (quality adjusted life years) have achieved considerable fame or perhaps even notoriety in health services policy making. Yet little has been done to date to assess the potential benefit in policy terms of studies that have used cost-utility analysis (CUA). It was in recognition of this fact that this particular investigation was undertaken. An evaluation of 51 cost-utility studies is reported in the paper. Several criteria were applied to each study including aspects of technical and policy relevance. The main findings were: few studies had been undertaken; they were limited to few areas of health care; their technical execution was often of poor quality; the majority of studies used the empirical findings of health state valuations obtained from original developers of different quality of life techniques; and many claimed their results to be 'favourable' (i.e. efficient interventions). This claim, however, is misguided because individual results get fed into generalised QALY league tables which ignore the context of specific studies and use results not performed on a common basis. Consequently, the state of the applied art of CUA is currently open to considerable question.

Cost-Benefit Analysis↗
PubMed1992

A cost utility analysis of mammography screening in Australia.

Cost utility analysis is the preferred method of analysis when quality of life instead is an important outcome of the project being appraised. However, there are several methodological issues to be resolved in implementing cost utility analysis, including whether to use generalised measures or direct disease specific outcome assessment, the choice of measurement technique, and the combination of different health states. Screening for breast cancer meets this criterion as mammographic screening has been shown to reduce mortality; and it is said that earlier treatment frequently results in less radical surgery so that women are offered the additional benefit of improved quality of life. Australia, like many other countries, has been debating whether to introduce a national mammographic screening programme. This paper presents the results of a cost utility analysis of breast cancer screening using an approach to measuring outcome, Healthy Year Equivalents, developed within this study to resolve these problems. Descriptions of breast cancer quality of life were developed from surveys of women with breast cancer, health professionals and the published literature. The time trade off technique was then used to derive values for breast cancer treatment outcomes in a survey of women in Sydney, Australia. Respondents included women with breast cancer and women who had not had breast cancer. Testing of (i) the effect of prognosis on the value attached to a health scenario; and (ii) whether the value attached to a health scenario remains constant over time has been reported. The estimate of the net costs of screening are reported. The costs of breast cancer screening include the screening programme itself, the further investigations and the subsequent treatment of breast cancer cases. Breast cancer is treated in the absence of screening, many commentators claim earlier treatment is costly but there is little evidence. Therefore we have investigated current patterns of breast cancer treatment, current use of investigations for women presenting with symptoms and current use of covert mammography screening. The results are extrapolated to obtain estimates of the costs and outcomes presented as cost per healthy year equivalent. This analysis produces important information for the Australian policy debate over mammography. It also contributes to the development of cost utility analysis and the approach developed here can be applied more generally.

Australia↗
PubMed1991

Minding our Ps and Qs? Financial incentives for efficient hospital behaviour.

In this paper, the empirical evidence addressing the particular issue of how hospitals may be reimbursed is reviewed. Most forthcoming is the indeterminate effect of prospective payment systems using diagnosis-related groups as a means of controlling costs. Such systems, by controlling only the price of hospital care, remain vulnerable to compensatory increase in patient throughput, cost-shifting and patient-shifting despite hospital cost per case being reduced. Health maintenance organisations have been shown to reduce hospital costs, but their effects on patients selection and patient outcome are unclear. Selective contracting in California (similar to the U.K. Government's proposed internal market) has also been shown to reduce costs by affecting both the price and quantity of hospital care. But these effects have occurred only in areas with high concentrations of hospitals. Global and clinical budgeting (which control price times quantity) seem to offer the most potential for cost reduction whilst maintaining patient outcome. By monitoring both cost and outcome within clinical budgets it should be possible to reduce wasteful variations in health care and so establish more efficient hospital practice.

Australia↗
PubMed1990

Counting the costs of mammography screening: first year results from the Sydney study.

Population-based mammography screening is a highly specialized service which aims to improve the early detection of breast cancer. This is achieved through the installation of a dedicated mix of medical technology and professional skills. It is therefore a resource-intensive activity so the benefits foregone by deploying these resources for mammography screening ought to be determined to investigate the relative efficiency of such a commitment. This paper describes the costing methodology used in the evaluation of the Sydney Breast X-ray Programme and presents the health service costs for the first 12 months of operation. In the first year when attendance was under 5000 it cost $118.93 to screen a woman, $13,817 to detect a cancer and $18,720 to detect an impalpable cancer. However, costs are expected to fall in subsequent years as attendance reaches capacity level. The first screening round will detect prevalent cancers; costs will change with subsequent screening rounds as incident cancers are detected. We are cautious in extrapolating the costs of a national programme from these results. However, on the basis of our data and disregarding treatment costs, a national programme which screened 70% of all Australian women over the age of 45 years every two years would add between $60 million and $100 million to the national health bill each year.

Aged↗
PubMed1989

Countering moral hazard in public and private health care systems: a review of recent evidence.

Within both publicly and privately financed health care systems different funding mechanisms have evolved, or have been proposed, to deal with the problem of 'moral hazard'. Moral hazard arises when financial incentives within the health care system lead to either inefficient demands for care by consumers or inefficient supply of care by providers. In this paper the problem of moral hazard is outlined in more detail, and different ways of countering moral hazard are reviewed in terms of three criteria: effect on patient utilisation of health services in general: effect on utilisation by different groups of patients; and effect on health status. It is concluded that evidence on different methods of funding health services can only be judged in the context of objectives. If the objectives of health care delivery are 'maintenance or improvement of health' and 'equal access for equal need' then charges of finance of care through health maintenance organisations both appear to be less favourable than 'free' care at the point of delivery whilst the latter is not necessarily more costly as a result. Research on other suggested alternatives is required, otherwise radical changes to health care financing in the UK will simply result in movement from one unproven system to another.

Capitation Fee↗
PubMed1989

The cost of diabetes.

This paper estimates the cost of diabetes in England and Wales in 1984 to be in excess of 259.5 million pounds. The costing methodology used follows the 'cost of illness' framework. This framework defines three elements for costing: direct, indirect and psychological, although the latter element is left out of the calculation because monetary valuations for this element have never been adequately estimated. Direct costs include resources used to prevent, detect, and treat diabetes. Indirect costs relate to the loss of productive output caused by absenteeism, early retirement, and premature mortality. The estimate which has been obtained is likely to be an underestimate because of the weaknesses and gaps in the data sets. The estimate of the total lost earnings from diabetes varied greatly according to the choice of absentee rate. If there was no significant difference between absenteeism in the diabetic community and the non-diabetic community then the cost of diabetes would be 259.5 million pounds. If on the other hand the diabetic community was prone to three times as much absenteeism as the non-diabetic community then the cost of diabetes would rise to 602.5 million pounds. The costs of diabetes as a subsidiary diagnosis are extremely difficult to identify. They have been estimated in this study to be 86 million pounds but this is thought to be an overestimate. Nevertheless the cost of diabetes is significant and thus the search for more efficient treatment regimens may reduce such costs as well as enhance the quality of life of the patients concerned.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1989

Paying general practitioners: shedding light on the review of health services.

This paper reviews evidence from recent research on the effects of different methods of remunerating general practitioners. Each method is examined in terms of patient use of health services in general, use of services by different groups in society and health outcome. Little is known about the effects of capitation as it currently exists in the UK, salaries or special payments for 'good practice', although evidence from British research is likely to be forthcoming on the last of these. Both health maintenance organizations and charges deter utilization, although little is known about the effect of this reduced demand. Furthermore, these two methods of financing health care appear to discriminate between members of society on lower and higher incomes in terms of both service use and health outcome. Fees for items of service provided tend to lead to unnecessary demands for fee yielding services by patients on the recommendation of their doctors. Although more evidence on different methods of remuneration is required, the importance of what is already known depends on the objectives of health care provision.

Capitation Fee↗
PubMed1988

An appraisal of the cost-effectiveness of alternative day care settings for frail elderly people.

Three alternative day care settings for a defined subgroup of frail elderly people are evaluated using cost-effectiveness analysis. This subgroup of frail elderly people is a significant minority of day-care users who have specific and separately identifiable needs. Their utilization of day care often results in the expensive use of day hospital resources or inappropriate social centre facilities. By using a mixture of published and original data sources this paper argues that specialist day services for frail elderly people can be considered at least as effective as either day hospital or social centre care. However, although it is concluded that the use of a specialist day service is more cost-effective than the day hospital, more analysis of the benefits of care in social centres is required before any judgement can be made about the relative cost-effectiveness between these settings.

Aged↗