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Biomedical subjects

N Hicks

Publications and source records attributed to N Hicks.

At least 19 recordsLinked to original sources
PubMed2001

A randomized controlled trial assessing the health economics of realtime teledermatology compared with conventional care: an urban versus rural perspective.

A randomized controlled trial was carried out to measure the cost-effectiveness of realtime teledermatology compared with conventional outpatient dermatology care for patients from urban and rural areas. One urban and one rural health centre were linked to a regional hospital in Northern Ireland by ISDN at 128 kbit/s. Over two years, 274 patients required a hospital outpatient dermatology referral--126 patients (46%) were randomized to a telemedicine consultation and 148 (54%) to a conventional hospital outpatient consultation. Of those seen by telemedicine, 61% were registered with an urban practice, compared with 71% of those seen conventionally. The clinical outcomes of the two types of consultation were similar--almost half the patients were managed after a single consultation with the dermatologist. The observed marginal cost per patient of the initial realtime teledermatology consultation was 52.85 Pounds for those in urban areas and 59.93 Pounds per patient for those from rural areas. The observed marginal cost of the initial conventional consultation was 47.13 Pounds for urban patients and 48.77 Pounds for rural patients. The total observed costs of teledermatology were higher than the costs of conventional care in both urban and rural areas, mainly because of the fixed equipment costs. Sensitivity analysis using a real-world scenario showed that in urban areas the average costs of the telemedicine and conventional consultations were about equal, while in rural areas the average cost of the telemedicine consultation was less than that of the conventional consultation.

Adolescent↗
PubMed2000

Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care: societal cost-benefit analysis.

OBJECTIVES: Comparison of real time teledermatology with outpatient dermatology in terms of clinical outcomes, cost-benefits, and patient reattendance. DESIGN: Randomised controlled trial with a minimum follow up of three months. SETTING: Four health centres (two urban, two rural) and two regional hospitals. SUBJECTS: 204 general practice patients requiring referral to dermatology services; 102 were randomised to teledermatology consultation and 102 to traditional outpatient consultation. MAIN OUTCOME MEASURES: Reported clinical outcome of initial consultation, primary care and outpatient reattendance data, and cost-benefit analysis of both methods of delivering care. RESULTS: No major differences were found in the reported clinical outcomes of teledermatology and conventional dermatology. Of patients randomised to teledermatology, 55 (54%) were managed within primary care and 47 (46%) required at least one hospital appointment. Of patients randomised to the conventional hospital outpatient consultation, 46 (45%) required at least one further hospital appointment, 15 (15%) required general practice review, and 40 (39%) no follow up visits. Clinical records showed that 42 (41%) patients seen by teledermatology attended subsequent hospital appointments compared with 41 (40%) patients seen conventionally. The net societal cost of the initial consultation was pound132.10 per patient for teledermatology and pound48.73 for conventional consultation. Sensitivity analysis revealed that if each health centre had allocated one morning session a week to teledermatology and the average round trip to hospital had been 78 km instead of 26 km, the costs of the two methods of care would have been equal. CONCLUSIONS: Real time teledermatology was clinically feasible but not cost effective compared with conventional dermatological outpatient care. However, if the equipment were purchased at current prices and the travelling distances greater, teledermatology would be a cost effective alternative to conventional care.

Adolescent↗
PubMed2000

A comparison of real-time and store-and-forward teledermatology: a cost-benefit study.

BACKGROUND: Increasing use of teledermatology should be based on demonstration of favourable accuracy and cost-benefit analysis for the different methods of use of this technique. Objectives To evaluate the clinical efficacy and cost-effectiveness of real-time and store-and-forward teledermatology. METHODS: Patients attended their own health centre and in the company of a general practitioner (GP) were seen by a hospital dermatologist over the videolink (real-time). Before the videolink consultation commenced, the GP took instant photographs of the skin lesion and posted them along with a standard referral letter to a different hospital dermatologist (store-and-forward). In total, 96 patients were seen by both real-time and store-and-forward teledermatology. Comparative diagnoses, clinical management plans, clinical outcomes and associated costs were made between the two types of teledermatology consultation. RESULTS: There was agreement between the videolink diagnosis and the still image diagnosis in 51% of cases. The same or similar management plan was recommended at both types of consultation in 44% of cases. Following the store-and-forward consultation the dermatologist recommended that 69% of patients required at least one hospital appointment compared with 45% of those patients seen in real-time. The net societal cost of the initial real-time consultation was pound132.10 per patient compared with &pound26.90 per patient for the initial store-and-forward consultation. CONCLUSIONS: The store-and-forward consultation was cheaper, but less clinically efficient, compared with the real-time consultation. The absence of interaction in a store-and-forward consultation limits the dermatologist's ability to obtain clinically useful information in order to diagnose and manage a patient satisfactorily.

Cost-Benefit Analysis↗
PubMed2000

A randomized controlled trial to assess the clinical effectiveness of both realtime and store-and-forward teledermatology compared with conventional care.

The clinical effectiveness of realtime teledermatology, store-and-forward teledermatology and conventional outpatient dermatological care were evaluated in a randomized control trial. A total of 204 patients took part--102 patients were randomized to the realtime teledermatology consultation, 96 of whose cases were also referred using a store-and-forward technique, and 102 to the conventional outpatient consultation. There were no differences in the reported clinical outcomes of realtime teledermatology and conventional dermatology. Of those randomized to the realtime teledermatology consultation, 46% required at least one subsequent hospital appointment compared with 45% of those randomized to the conventional outpatient consultation. In contrast, the dermatologist requested a subsequent hospital appointment for 69% of those seen by store-and-forward teledermatology. An analysis of costs showed that realtime teledermatology was clinically feasible but more expensive than conventional care, while the store-and-forward teledermatology consultation was less expensive but its clinical usefulness was limited. Sensitivity analysis indicated that realtime teledermatology was as economical as conventional care when less artificial assumptions were made about equipment utilization, costs and travel distances to hospital.

Adolescent↗
PubMed1999

Patient cost-benefit analysis of teledermatology measured in a randomized control trial.

A randomized controlled trial of the costs and benefits of teledermatology consultations compared with traditional hospital consultations was carried out. Over a nine-month period, 197 patients were referred from general practice for a dermatological opinion, 98 for a teledermatology consultation and 99 for a hospital consultation. Eighty patients required an additional subsequent hospital appointment. Patients were asked to complete an economic questionnaire after each consultation, and 164 questionnaires were returned: 62% of those randomized to the teledermatology consultation responded compared with 58% of those randomized to the hospital consultation. Patients seen by teledermatology at their own health centre had shorter distances to travel and spent less time overall attending the appointment compared with those seen at the hospital. However, the teledermatology consultations were more time-consuming for the general practitioner and dermatologist. These findings indicate that teledermatology has more benefits for the patient than for the health-care delivery team.

Adolescent↗
PubMed1998

Sailing without radar: an excursion in resource allocation.

This paper deals with the knowledge base employed in resource allocation. It deliberately distinguishes between 'thick-textured' and 'thin-textured' knowledge. A thick-textured view of change in the health sector accounts for the history, civic goods and variety of human needs and passions which rationalist economics defines out as a thin-textured matter of individual choices in a free market. The narrative material begins with a discussion of health service policy-making in South Australia and elsewhere in the 1980s and 1990s, then proceeds to a discussion of priority-setting literature, which we regard as thin-textured. We offer two accounts of approaches to setting priorities in health care which we think have overcome some of the deficiencies of the thin-textured approach.

Community Participation↗
PubMed1996

Rating the quality of evidence for clinical practice guidelines.

This article describes the system for rating the quality of medical evidence developed and used during creation of the Agency for Health Care Policy and Research-sponsored heart failure guideline. Previous approaches to rating evidence were not designed for use in the setting of clinical practice guidelines. The present system is based on the tenet that flaws in research design are serious to the extent they threaten the validity of the results of studies. A taxonomy of major and minor flaws based on that tenet was developed for randomized controlled trials and for cohort and medical registry studies. The use of the system is described in the context of two difficult clinical issues considered by the Panel: the role of coronary artery revascularization and the use of metoprolol.

Bias↗
PubMed1996

Health status measurement and the assessment of medical care.

This article reviews the role of health status measures in the assessment of medical care. It is argued that such measures are of only limited value in assessing the performance of health care professionals and institutions because of confounding factors, problems of data collection and the play of chance. Nevertheless, health status measures should be incorporated as outcome measures into clinical trials since they can provide information on how individuals and institutions can improve performance and give health policy makers information about the effectiveness of interventions. It is concluded that the development of simpler measures of performance would be more practical than trying to overcome the limitations of health status measures in monitoring the quality of health care institutions.

Health Policy↗
PubMed1995

Detecting differences in quality of care: the sensitivity of measures of process and outcome in treating acute myocardial infarction.

The merits or otherwise of publishing hospital specific death rates are much debated. This article compares the relative sensitivity of measures of process and outcome to differences in quality of care for the hospital treatment of myocardial infarction. Aspects of hospital care that have a proved impact on mortality from myocardial infarction are identified, and the results from meta-analysis and large randomised controlled trials are used to estimate the impact that optimal use of these interventions would have on mortality in a typical district general hospital. Sample size calculations are then performed to determine how many years of data would be needed to detect significant differences between hospitals. A comparison is then made with the amount of data that would be needed to detect significant differences if information about process of care was being collected. Process measures based on the results of randomised controlled trials were found to be able to detect relevant differences between hospitals that would not be identified by comparing hospital specific mortality, which is an insensitive indicator of the quality of care.

Hospital Mortality↗
PubMed1994

Pain after laparoscopy: an observational study and a randomized trial of local anesthetic.

Our objective was to determine if local anesthesia reduces pain after a laparoscopy. Eighty women were assigned randomly 10 ml of 0.5% bupivacaine or 0.9% saline flushed over the peritoneal folds and into the abdominal wall after laparoscopy under general anesthesia. Pain scores from the deep abdomen, skin, shoulder, and back were collected 30 min, 2 h, 4 h, and the day following laparoscopy. Pain scores also were correlated with patients' height, weight, operative findings, surgical technique and procedure, and volume of gas insufflated into the abdomen. Bupivacaine has a small effect on abdominal and skin pain 2 h after surgery (p = 0.01) but has no effect on shoulder or back discomfort. Women who have been sterilized, have not had previous abdominal surgery, or have evidence of old pelvic inflammation report more postoperative backache and deep abdominal pain but no greater skin or shoulder discomfort. Weight, height, whether the abdominal wall was picked up, and the volume of gas used to insufflate the abdomen are independent of all postoperative pain scores. Local anaesthetic instilled down the laparoscopy trocar reduces skin discomfort 2 h after surgery, but this beneficial effect is small compared with other factors influencing pain after laparoscopy.

Anesthesia, General↗
PubMed1994

Getting research into practice: facing the issues.

The translation of research into practice is currently a high-profile issue in the NHS. A number of regions have undertaken work in this area. Reports on a project that is part of the Anglia and Oxford Regions's "getting Research into Practice" (GRiP) initiative. The work focuses on the use of steroids in pre-term delivery, a procedure that medical evidence suggests can reduce neo-natal mortality and morbidity. Presents a number of findings which suggest that getting research into practice does not merely rest on the availability of well-researched evidence.

Attitude of Health Personnel↗
PubMed1993

The relationship between a severity of illness indicator and mortality and length-of-stay.

One important determinant of the cost and outcome of medical care is the severity of illness; there is no routinely available severity measure used in the United Kingdom. An American clinical information system, Medisgroups, was used to allocate 2,279 general medical patients to one of five admission severity groups in an English teaching hospital. The results showed a highly significant association between increasing severity and both length-of-stay and mortality. However, a further analysis of patients in the ten most common Diagnosis Related Groups showed that diagnostic group alone accounted for about twice the amount of variation explained by severity. The addition of severity to Diagnosis Related Groups only gave a very small rise in the overall explanatory power. These results are broadly consistent with those from larger American studies, which suggest that severity of illness at admission may not be as important as widely supposed in explaining variations in length-of-stay and mortality.

Diagnosis-Related Groups↗