Priority-setting and rationing in healthcare: Evidence from the English experience

In a context of ever increasing demand, the recent economic downturn has placed further pressure on decision-makers to effectively target healthcare resources. Over recent years there has been a push to develop more explicit evidence-based priority-setting processes, which aim to be transparent and inclusive in their approach and a number of analytical tools and sources of evidence have been developed and utilised at national and local levels. This paper reports findings from a qualitative research study which investigated local priority-setting activity across five English Primary Care Trusts, between March and November 2012. Findings demonstrate the dual aims of local decision-making processes: to improve the overall effectiveness of priority-setting (i.e. reaching ‘correct’ resource allocation decisions); and to increase the acceptability of priority-setting processes for those involved in both decision-making and implementation. Respondents considered priority-setting processes to be compartmentalised and peripheral to resource planning and allocation. Further progress was required with regard to disinvestment and service redesign with respondents noting difficulty in implementing decisions. While local priority-setters had begun to develop more explicit processes, public awareness and input remained limited. The leadership behaviours required to navigate the political complexities of working within and across organisations with differing incentives systems and cultures remained similarly underdeveloped.     

Current surgical management of melanoma

The surgical management of melanoma has changed dramatically over the last few decades. Through the development and conduction of well-designed, prospective, randomized trials, we have been able to refine the way that we surgically manage patients with melanoma. Indeed, many important issues have been addressed through such trials: the proper surgical margins for the primary melanoma, utility of the elective lymph node dissection and the role for selective lymphadenectomy, to name a few. This review will also discuss what we have learned from past clinical trials and address several issues with regards to where we are going in the future.     

Impact of the sustained control of cardiovascular risk factors on first episode heart failure: The relevant role of primary care

Background: The role of cardiovascular risk factor control in the development of heart failure (HF) has not yet been clearly established.

Objective: To determine the effect of cardiovascular risk factor control on the occurrence of a first episode of hospital admission for HF.

Methods: A case-control study using propensity score-matching was carried out to analyse the occurrence of first hospital admission for HF taking into account the degree of cardiovascular risk factor control over the previous 24 months. All patients admitted to the cardiology unit of the Hospital del Mar between 2008 and 2011 because of a first episode of HF were considered cases. Controls were selected from the population in the hospital catchment area who were using primary care services. Cardiovascular risk factor measurements in the primary healthcare electronic medical records prior to the first HF episode were analysed.

Results: After the matching process, 645 participants were analysed (129 HF cases and 516 controls). Patients suffering a first HF episode had modest increments in body mass index and blood pressure levels during the previous two years. Adjusted odds ratio for experiencing a first HF hospital admission episode according to systolic blood pressure levels and body mass index was (OR: 1.031, 95% CI: 1.001–1.04), and (OR: 1.09, 95% CI: 1.03–1.15), respectively.

Conclusion: Increased levels of body mass index and systolic blood pressure during the previous 24 months may determine a higher risk of having a first HF hospital admission episode.     

Forty-Two Months Experience of Flupenthixol Decanoate in the Maintenance Treatment of Schizophrenia

Summary

Further experience with maintenance depot treatment of 199 schizophrenic patients over a 42-month period has confirmed an earlier report by the same investigators of the effectiveness of flupenthixol decanoate as an antipsychotic agent and its value in maintaining schizophrenics in the community. Ten percent of patients required re-admission to hospital for treatment of psychotic relapse during this 3\-year period. Over the whole period only 28% of patients showed extrapyramidal side-effects, in most cases trivial in degree, so that the routine prophylactic prescribing of anti-parkinsonism drugs with flupenthixol decanoate would appear to be unjustified. Depression was noted in 15 % of patients (10 % severe; 5 % moderate), an incidence which, though no higher than that encountered in fluphenazine-treated patients, was disappointingly high for a drug used, in lower dosage, specifically for the treatment of neurotic depression. Other side-effects noted were transient hypomania and anergia, each in 7% of the group. There was no unequivocal evidence of toxicity. The mean dose required by the first 78 patients (31.97 to 33.46?mg./3 weeks) did not vary very significantly over a 2-year treatment period.     

LeisureIRecreation Needs of Hospitalized Elderly:

Leisure/Recreation interests and needs do not change much as a person grows older, or as a person becomes hospitalized. Certainly opportunities do change as internal and external limitations are imposed. Patients' interests and needs are going to be highly individualized, just as our own are. For this reason, variety and flexibility need to be built into the environment. Nonetheless, the major factor in providing sensitive human care continues to be the personnel providing that care. A management philosophy which nourishes an interdisciplinary model and one which supports quality of life, as well as extension of years, will be essential in any setting.     

The Continuing Story of the Cost-Effectiveness of Photoselective Vaporization of the Prostate versus Transuretheral Resection of the Prostate for the Treatment of Symptomatic Benign Prostatic Obstruction

BackgroundIn 2008, a UK assessment of technologies for benign prostatic obstruction concluded negatively about photoselective vaporization of the prostate (PVP), and the 2010 National Institute for Health and Care Excellence guidance caused several UK institutions to abandon PVP.ObjectiveTo reassess the costs and effects of PVP versus transurethral resection of the prostate (TURP) on the basis of most recent data.MethodsThe same model was used as in 2008. Transition probabilities were estimated using a Bayesian approach updating the 2008 estimates with data from two meta-analyses and data from GOLIATH, the latest and largest trial comparing PVP with TURP. Utility estimates were from the 2008 assessment, and estimates of resource utilization and costs were updated. Effectiveness was measured in quality-adjusted life-years gained, and costs are in UK pounds. The balance between costs and effects was addressed by multivariate sensitivity analysis.ResultsIf the 2010 National Institute for Health and Care Excellence analysis would have updated the cost-effectiveness analysis with figures from its own meta-analysis, it would have estimated the change in quality-adjusted life-years at −0.01 (95% confidence interval [CI] −0.05 to 0.01) instead of at −0.11 (95% CI −0.31 to −0.01) as in the 2008 analysis. The GOLIATH estimate of −0.01 (95% CI −0.07 to 0.02) strengthens the conclusion of near equivalence. Estimates of additional costs vary from £491 (£21−£1286) in 2008 to £111 (−£315 to £595) for 2010 and to £109 (−£204 to £504) for GOLIATH. PVP becomes cost saving if more than 32% can be carried out as a day case in the United Kingdom.ConclusionsThe available evidence indicates that PVP can be a cost-effective alternative for TURP in a potentially broad group of patients.     

Knowledge of the patient as decision‐making power: staff members' perceptions of interprofessional collaboration in challenging situations in psychiatric inpatient care

Challenging situations in psychiatric inpatient settings call for interprofessional collaboration, but the roles and responsibilities held by members of different professions is unclear. The aim of this study was to describe staff members' perceptions of interprofessional collaboration in the context of challenging situations in psychiatric inpatient care. Prior to the study taking place, ethical approval was granted. Focus group interviews were conducted with 26 physicians, ward managers, psychiatric nurses, and nursing assistants. These interviews were then transcribed and analysed using qualitative content analysis. Results described participants' perceptions of shared responsibilities, profession‐specific responsibilities and professional approaches. In this, recognising knowledge of the patient as decision‐making power was understood to be a recurring theme. This is a delimited qualitative study that reflects the specific working conditions of the participants at the time the study was conducted. The findings suggest that nursing assistants are the most influential professionals due to their closeness to and first‐hand knowledge of patients. The results also point to the possibility of other professionals gaining influence by getting closer to patients and utilising their professional knowledge, thus contributing to a more person‐centred care.