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Biomedical subjects

T Walley

Publications and source records attributed to T Walley.

At least 91 records · Page 5Linked to original sources
PubMed1996

Local clinical guidelines: description and evaluation of a participative method for their development and implementation.

BACKGROUND: National guidelines are rarely followed by immediate change in clinical behaviour. We present our experience of an active educational method for local development and implementation of a guideline. OBJECTIVE: To evaluate the effectiveness of a participative method for developing local clinical guidelines. METHODS: A trial in a district of the effect of guideline development incorporating active participation of intended recipients on subsequent relevant prescribing. It was carried out in Wirral Family Health Services Authority district (the Wirral peninsula) comprising 69 general practices covering a population of 345,763. An exemplar guideline on 'hypertension in the elderly' was developed by the method described. The principal recommended drug was bendrofluazide 2.5 mg once daily. The differences in prescribed daily doses (PDD) of bendrofluazide 2.5 mg tablets per quarter per 1000 prescribing units (age-weighted population) between the intervention district and England as a whole was measured. RESULTS: Comparison of the intervention district with England data demonstrates a median difference of 122.49 PDD before and 206.34 PDD after guideline production, this change is statistically highly significant (Mann-Whitney two-tailed P < 0.0001; 95% CI = 36.51-104.77). Grouped regression analysis shows no significant difference (0.89) in slope gradients before guideline production (P = 0.35, 95% CI = -3.97-5.76), but the difference in slope gradients after (12.95) is statistically highly significant (P < 0.0001; 95% CI = 8.17-17.73). The data suggests that the change in clinical behaviour persisted for at least two years. CONCLUSION: Participation of intended recipient general practitioners and local specialists in the development of a guideline by an active educational method as described was followed by a favourable change in clinical behaviour which persisted for at least two years.

Aged↗
PubMed1996

Effective contracting of high-tech health care for patients at home.

High-technology treatments such as total parenteral nutrition or intravenous antibiotics may increasingly be provided to patients at home. In the past, these services have been funded by the NHS prescribing budget. The aim of the Department of Health's Executive letter EL(95)5, Purchasing High Tech Healthcare for Patients at Home was to ensure that contracts placed by health authority purchasers maintain effective patient services and obtain better value for money by encouraging competition between potential homecare providers. Examines contracting for high-tech health care for patients at home and suggests that efficiency could be improved when contracting with commercial home-care organizations by lead purchasing arrangements. In the long-term, contracting with NHS tertiary centres is most likely to ensure continuity of care and appropriate clinical monitoring of patients.

Contract Services↗
PubMed1996

Contracting for high-tech health care for patients at home: a survey of purchaser responses.

Points out that the Department of Health's Executive Letter: EL(95)5 moved the finance of high technology treatment provided at home for chronically ill patients from the NHS prescribing budget onto a defined and consistent framework. The aim was to obtain better value for money by encouraging competition between potential homecare providers. Reports on a survey of prescribing advisers of purchasing health authorities, which focused on their response to these developments, and discusses the issues identified by purchasers in their implementation of EL(95)5. Notes that, although most purchasers chose to contract directly with a single commercial homecare organization in 1995-1996, there was no consensus about where contracts should be placed in the future, and that the purchasers identified inefficiencies in contracting for such care. Discusses methods of improving the purchasers' response to contracting.

Attitude of Health Personnel↗
PubMed1996

Same information, different decisions: the influence of evidence on the management of hypertension in the elderly.

BACKGROUND: Evidence-based medicine requires general practitioners (GPs) to act upon the results of clinical trials. Clinical trial evidence may be difficult to understand and apply in practice. AIM: To investigate whether GPs were unduly influenced in managing hypertension in the elderly by the ways in which benefits of trial results were presented, and to establish whether their current treatment of an elderly hypertensive patient was broadly in line with recent clinical trial evidence. METHOD: Seventy-three GPs attending a refresher course were given a written questionnaire containing data from one clinical trial of treatment of hypertension in the elderly presented in four different ways (absolute risk reduction, relative risk reduction, difference in event-free patients, and number of patients who had to be treated in order to prevent one clinical event), as if from four different trials. The effect of each presentation on treatment preferences was assessed using Likert scales. The results were analysed to determine whether the method of presentation of results influenced decision making. A clinical scenario was presented to investigate their current treatment preferences in an elderly hypertensive. RESULTS: All GPs returned completed questionnaires. Relative risk reduction was the only presentation which was significantly different from the others, and was the most likely to influence prescribing. In free-text comments, 75% of GPs admitted having problems understanding statistics commonly found in medical journals. More than 90% conformed with recent clinical trial evidence for the management of hypertension. CONCLUSION: GPs were most influenced by relative risk reduction, and were unaware of how the presentation of research results could affect treatment decisions. Most GPs freely admitted to difficulty in comprehending medical statistics. Almost all of the GPs expressed treatment decisions which were broadly in line with clinical evidence.

Aged↗
PubMed1995

Alterations in prescribing by general practitioner fundholders: an observational study.

OBJECTIVES: To compare prescribing in general practices before and after they become fundholders to assess whether this affected prescribing patterns. DESIGN: Analysis of prescribing data (PACT) for one year before and one year after practices become first, second, or third wave fundholders and comparison with practices that were not fundholders during any part of the study. MAIN OUTCOME MEASURES: Prescribing costs (net ingredient cost per prescribing unit), prescribing volume (items per 1000 prescribing units), net ingredient cost per item, and percentage of generic prescribing. SETTING: Former Mersey Regional Health Authority. SUBJECTS: 100 fundholders (20 first wave, 31 second wave, 49 third wave) and 312 nonfundholders. RESULTS: Prescribing costs and volume rose throughout the study in all groups. In all three fundholding waves the rate of increase of prescribing costs was significantly lower than for nonfundholders. Both cost per item and prescribing volume tended to decrease, the former probably because of a significant increase in generic prescribing. Fundholding and non-fundholding practices differed in several respects. CONCLUSION: Fundholding has altered practice prescribing patterns compared with those of nonfundholders, increasing generic prescribing and reducing the rate of increase of prescribing costs.

Drug Costs↗
PubMed1995

A purchaser perspective of managing new drugs: interferon beta as a case study.

Many new drugs in the future will be very expensive and have major resource implications. Given current structures and legislation covering the prescribing of drugs, there are no clear means of controlling the use of these drugs to avoid diverting money away from other health care services and into drug treatment. This paper considers what mechanisms might be used by a purchaser to manage the introduction of an expensive new drug and uses interferon beta-1b for treating multiple sclerosis as an example. The most likely mechanism is the prescribing of the drug by a general practitioner on the advice of a neurologist. This would achieve a good benefit for the resources invested but would not control total expenditure. Devolving a limited budget for the drug to a specialist centre so that neurologists may prescribe it directly would be preferable, as this would link clinical, prescribing, and budgetary responsibility. These issues need to be addressed urgently by purchasers if major disruptions of services are to be avoided.

Drug Approval↗
PubMed1995

Current prescribing in primary care in the UK. Effects of the indicative prescribing scheme and GP fundholding.

The costs of drugs prescribed in primary care in the UK continue to rise despite a variety of government initiatives. Two of the major initiatives are considered here in detail: the Indicative Prescribing Scheme (IPS), and general practitioner (GP) fundholding, both of which began in 1991. Other more recent initiatives are also described, including the selected list, the Pharmaceutical Pricing Regulatory Scheme and the move to relicense drugs for nonprescription sale. The IPS has generally failed to control the rise in drug costs because of unrealistic targets, organisational difficulties (including the lack of adequate data to set budgets properly) and because there was neither incentive nor penalty to encourage compliance on the part of the GP. The IPS stresses cost containment, and makes little allowance for the consideration of quality of appropriateness of prescribing. Despite this disappointment, the IPS is continuing, and the future of the scheme is discussed here. GP fundholding, in contrast, has reduced the rate of rise of drug costs in participating GP practices, although it has not actually reduced drug costs. There have been a number of studies of this model, which are discussed here. The clear financial incentive to fundholders encourages them to restrain drug costs. Attempts to extend similar incentives to nonfundholding GPs are also described. Although there is a commitment on the part of the government to encourage and make use of data about economic evaluations of drug therapy and other medical interventions, so far the emphasis has been exclusively on cost containment. In this paper, we consider possible mechanisms by which this might be improved.

Cost-Benefit Analysis↗
PubMed1994

Clinical pharmacology and therapeutics in undergraduate medical education in the UK: current status.

1. Medical undergraduate education is currently undergoing major changes in the UK in response to calls for the development of a core curriculum. Teaching in clinical pharmacology and therapeutics will also change to meet these demands. A postal survey was conducted to assess the current status of teaching in these subjects. 2. A questionnaire based on previous similar surveys conducted elsewhere was sent to departments or individuals in 27 medical schools in the UK; 22 (81%) replied. 3. Departmental priorities were defined as (in order): clinical research, undergraduate teaching, basic scientific research and clinical service provision. No change in these priorities in the future was foreseen by respondents. 4. Teaching methods were for the most part traditional, with the lecture as the most widely used and important technique. Specific clinical teaching was conducted by some and was considered very important by them. Teaching by problem solving was much less common. 5. Respondents were asked for free text comments; many of the remarks suggested dissatisfaction with the resources and time currently available for teaching in clinical pharmacology and therapeutics. Some expressed significant concerns that their teaching commitment would be reduced further by the development of the core curriculum.

Education, Medical, Undergraduate↗
PubMed1994

Clinical pharmacology and therapeutics in undergraduate medical education in the UK: the future.

1. Changes in undergraduate medical education will involve the development of a core curriculum of material of essential knowledge and of the skills for self directed learning both as a student and a postgraduate. A survey of departments or individuals teaching clinical pharmacology and therapeutics was conducted to consider what a core curriculum in these subjects might contain and how changes in the school curriculum would affect teaching in the future. 2. A questionnaire was developed based on an American consensus statement on the core curriculum in clinical pharmacology and therapeutics. Freetext answers were encouraged. Twenty-seven medical schools were surveyed; 21 (78%) replied. 3. Items of core knowledge (as defined by the American statement) were generally rated important or very important. The most important were considered to be (in order): prescribing for the elderly, management of overdose and adverse drug reactions. All of these were widely taught (85-100%). The least important items were the efficacy and toxicity of nonprescription drugs (taught by 35%) and the process of drug development and approval (taught nevertheless by 95%). 4. Core skills were generally rated less important, and less often taught. It was felt by many respondents that these skills, as defined, were excessively detailed for British undergraduates and more appropriate for postgraduate education. 5. Core attitudes were rated as being of intermediate importance, but not widely taught as it was felt that these could best be inculcated by example rather than formal teaching. Again, many felt that these attitudes were inappropriate for a UK core curriculum.(ABSTRACT TRUNCATED AT 250 WORDS)

Curriculum↗