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N Freemantle

Publications and source records attributed to N Freemantle.

At least 73 records · Page 4Linked to original sources
PubMed1999

Does the UK National Health Service need a fourth hurdle for pharmaceutical reimbursement to encourage the more efficient prescribing of pharmaceuticals?

Reform of the existing mechanisms that influence pricing for pharmaceuticals in the UK NHS is overdue. Currently, the prescribing pricing policy favours the needs of industry over those of the NHS and of individual patients. In a recent consultation document, the UK Government indicated an emerging policy that will provide for the assessment of the effectiveness and cost effectiveness of important pharmaceuticals in the NHS. In developing and implementing this policy, much can be learnt from the situation in Australia, where pricing of drugs is related directly to an assessment of their value for money in specific patient groups. In fact, the differing circumstances between the UK and Australia suggest that the progress achieved by the Australians may be supplemented by further reform to encourage a more rational relationship between the NHS and the pharmaceutical industry. Australia has led the world in demonstrating that a modest form of assessment of 'value for money' may be incorporated practically in the process of licensing and reimbursing new drugs. It is important that this finding is built upon in the UK NHS for the benefit of patients and for society as a whole. It is not clear that the current proposals for reform from the UK Department of Health go far enough to achieve the required changes in drug licensing and regulation.

Australia↗
PubMed1999

A framework for incorporating cost-effectiveness in evidence-based clinical practice guidelines.

In England, recent health care reforms emphasise the role of clinical guidelines in promoting effective and efficient health care. Introducing economic data into guidelines raises some methodological issues: specifically, the provision of valid and generalisable cost estimates, the weight placed upon cost 'evidence', and the presentation of cost-effectiveness information in a manner accessible to clinicians. A series of primary care guidelines, explicitly including consideration of health economic information, have recently been published, intended to help clinicians to aggregate the attributes of treatment choices to derive treatment recommendations consistent with both the clinical decision-making process and social objectives. Clinicians involved in developing guidelines responded well to the process and consistently managed to agree treatment recommendations, often after considerable debate about the evidence for treatment. In none of the guideline areas, all of which addressed common diseases, was there adequate information to estimate a cost per quality-adjusted-life-year, and it is unclear how helpful this approach would have been had it been possible. The implications of this method are discussed, guidance offered for economists new to guideline development and future areas of work identified.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1999

A randomized trial of Evidence-based OutReach (EBOR): rationale and design.

There is increasing interest in evaluating the methods used to implement the findings from medical research. This paper describes the Evidence-based OutReach (EBOR) trial, which is the first large randomized study in the United Kingdom that will evaluate the effectiveness and efficiency of educational outreach visits by trained pharmacists who are delivering messages derived from four evidence-based clinical practice guidelines. General practices form the unit of allocation and analysis. The study design addresses important factors that may influence the effectiveness of the intervention, such as the pharmacist who delivers the messages, the health authority in which practices are located, and the size of a practice.

Family Practice↗
PubMed1999

Perindopril for elderly people with chronic heart failure: the PEP-CHF study. The PEP investigators.

BACKGROUND: The prevalence of chronic heart failure (CHF) rises with increasing age, from < 1% in those below 65 years of age to > 5% in those over 65 years of age and is a major cause of morbidity and mortality in older people. Recent European guidelines point to a major deficiency in our knowledge of how to treat diastolic chronic heart failure, and a lack of information on treatment for heart failure in the elderly in general. AIMS: The aims of this trial are to assess the potential benefits of the ACE inhibitor perindopril to treat chronic heart failure in elderly people, in the absence of any major left ventricular systolic dysfunction. SUBJECTS: One thousand people over the age of 70 years will be recruited into this study. Evidence of chronic heart failure will be confirmed by clinical criteria and echocardiography. METHODS: Once a diagnosis of chronic heart failure has been confirmed, the patient will receive either perindopril or placebo in addition to their usual treatment. Death, and unplanned heart failure related hospitalisations, are the primary outcomes. Quality of life, as measured by the Guyatt questionnaire will be assessed at the beginning of the study and at 1 year. Sub-studies of this trial include a 6-min walking test and more detailed evaluation of ventricular function (as assessed by echocardiography). Both parameters will be measured at 8 weeks and 1 year, and analysed against baseline data. Cognitive function in this group of patients will also be evaluated at baseline and 1 year. This trial is due to report in the year 2001.

Aged↗
PubMed1999

Changing doctor prescribing behaviour.

The aim of this overview was to identify interventions that change doctor prescribing behaviour and to derive conclusions for practice and further research. Relevant studies (indicating prescribing as a behaviour change) were located from a database of studies maintained by the Cochrane Collaboration on Effective Professional Practice. This register is kept up to date by searching the following databases for reports of relevant research: DHSS-DATA; EMBASE; MEDLINE; SIGLE; Resource Database in Continuing Medical Education (1975-1994), along with bibliographies of related topics, hand searching of key journals and personal contact with content area experts. Randomised controlled trials and non-equivalent group designs with pre- and post-intervention measures were included. Outcome measures were those used by the study authors. For each study we determined whether these were positive, negative or inconclusive. Positive studies (+) were those that demonstrated a statistically significant change in the majority of outcomes measured at level of p < or = 0.05 between the intervention and control groups. Negative studies (-) showed a significant change in the opposite direction and inconclusive studies (approximately) showed no significant change compared to control or no overall positive findings. We identified 79 eligible studies which described 96 separate interventions to change prescribing behaviour. Of these interventions, 49 (51%, 41%-61%) showed a positive significant change compared to the control group but interpretation of specific interventions is limited due to wide and overlapping confidence intervals.

Data Collection↗
PubMed1999

Choosing an appropriate unit of analysis in trials of interventions that attempt to influence practice.

The choice of an appropriate unit of analysis in evaluations in health policy is problematic and errors are frequently made which may undermine study conclusions. This paper describes the structure of randomized trials, issues concerning randomization and replication, and the factors that should be considered when deciding upon the appropriateness of a unit of analysis.

Data Interpretation, Statistical↗
PubMed1999

Designing evaluations of interventions to change professional practice.

The design and interpretation of experimental studies to examine the effectiveness and efficiency of implementation strategies intended to change professional practice are gaining increasing attention. It has been argued that variations of the simple randomised design are most appropriate in this setting. The principles of block designs and their applicability in this field are reviewed critically, as are the choice of outcomes and approaches to economic analysis. We conclude that more complex designs are not superior per se, and that the design, choice of implementation method and topic, and analysis of such experiments should reflect the circumstances of the study.

Bias↗
PubMed1999

Deriving treatment recommendations from evidence within randomized trials. The role and limitation of meta-analysis.

Meta-analysis is commonly used in reviews of the effectiveness of medical technologies, but this approach has not been used in direct support of guidelines development groups. This paper describes the approach of the North of England Guidelines Development Project in describing the evidence using meta-analyses that were conducted explicitly to address questions on the choice of therapy raised by the guidelines development groups. Particular emphasis is placed on the context within which the contributing trials were conducted and the extent to which systematic differences between trials (heterogeneity) was observed, described, and explained. There is a trade-off between internal and external validity for different metrics when presenting the results of trials. More interpretable metrics, such as risk differences or weighted mean differences, are confounded by study design issues and strong assumptions. More robust measures such as odds ratios or standardized weighted mean differences are difficult to interpret physically. Individual patient data may prove particularly helpful in addressing pivotal questions on the magnitude of effects of interventions, though accessing and reanalyzing these data requires a substantial investment in time and other resources.

Bias↗
PubMed1998

Evidence into practice. Prescribing selective serotonin reuptake inhibitors.

This descriptive analysis examines prescribing trends of antidepressants in English primary care, providing analysis of NHS reimbursement data for groups of antidepressants between 1989 and 1994. Prescribing trends seem unaffected by the release of information on the effectiveness and cost-effectiveness of antidepressant drugs. We found that simple distribution of the results of health technology assessments may not be sufficient to influence practice.

Depression↗
PubMed1998

Evidence into practice, experimentation and quasi experimentation: are the methods up to the task?

OBJECTIVE: Methodological review of evaluations of interventions intended to help health professionals provide more effective and efficient health care, motivated by the current experience of NHS Research and Development in England. Emphasis upon the forms of research appropriate to different stages in the development and evaluation of interventions, the use of experimental and quasi experimental designs, the methods used in systematic reviews and meta analyses. METHOD: A proposed development process is derived from that used in the development of drugs. The strengths and weaknesses of different experimental and quasi experimental designs are derived from published methodological literature and first principles. Examples are drawn from the literature. RESULTS: Like pharmaceuticals, implementation interventions need to go through several stages of development before they are evaluated in designed experiments. Where there are practical reasons that make random allocation impossible in quantitative evaluations, quasi experimental methods may provide useful information, although these studies are open to bias. It is rare for a single study to provide a complete answer to important questions, and systematic reviews of all available studies should be undertaken. Meta analytic techniques go some way towards countering the low power of many existing studies, reduce the risk of bias, and avoid the subjective approaches that may be found in narrative reviews. CONCLUSIONS: The initiative taken by NHS Research and Development in examining methods to promote the uptake of research findings is welcome, but will only prove helpful if careful attention is paid to the different stages of the development process, and different research approaches are used appropriately at different stages.

Humans↗