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.     

Longitudinal person-centered measurement: A psychometric evaluation of the Preparedness for Colorectal Cancer Surgery Questionnaire (PCSQ)

ObjectiveThe Preparedness for Colorectal Cancer Surgery Questionnaire (PCSQ) was previously developed in Swedish to assess patients’ knowledge seeking and sense making capabilities. Aiming to measure preparedness at different phases during the pre-surgery and recovery period, the objectives were to (a) evaluate psychometric properties of the longitudinal PCSQ, (b) establish measurement invariance over time, and (c) describe change in preparedness.MethodsElective colorectal cancer surgery patients completed a questionnaire at five time points from pre-surgery until 6 months post-surgery (n = 250). The longitudinal PCSQ consists of 23 items measuring four domains: Searching for and making use of information, Understanding and involvement in care, Making sense of recovery, Support and access to care. Psychometric analyses, including confirmatory factor analysis, were applied to evaluate internal consistency reliability and ascertain invariance over time of the measurement structure and parameters.ResultsThe psychometric analyses revealed good fit of the measurement models, high internal consistency reliability (≥.94), and support for configural, metric and scalar measurement invariance of the four PCSQ domains. Patients reported lower levels of preparedness after surgery than pre-surgery.ConclusionThe adapted version of the PCSQ can be used for longitudinal analyses.Practice implicationsThe measurement of preparedness is important for evaluating person-centred outcomes before and during recovery from colorectal cancer surgery.     

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.     

Long‐term tooth loss in periodontally compromised but treated patients according to the type of prosthodontic treatment. A retrospective study

If prosthodontic treatment is considered after periodontal therapy, the questions arise i) does prosthodontic treatment affect the treatment outcome of the dentition in general and ii) which type of prosthesis is related to best treatment outcome of abutment teeth? Our goal was to compare long‐term tooth loss after comprehensive periodontal therapy in patients with or without prosthodontic treatment. Ninety patients' charts with a total of 1937 teeth who had received comprehensive periodontal treatment 5–17 years ago by the same periodontist were retrospectively evaluated. Sixty‐five patients received fixed dental prostheses (FDP; n = 29) and/or removable partial dentures anchored with clips (RPDC; n = 25) or double crowns (RPDD; n = 25). Twenty‐five patients were also periodontally compromised but treated without prosthodontic treatment and served as a control group. A total of 317 teeth and 70 abutment teeth were lost during 9·7 ± 4·1 years of observation. Thereof, 273 teeth and 48 abutment teeth were lost due to periodontal reasons. Mean tooth loss amounted to 1·2 ± 1·5 (controls) and 4·4 ± 3·4 (partial dentures). Abutment tooth loss was 0·4 ± 1·1 (FDP), 1·0 ± 1·2 (RPDC) and 1·3 ± 1·0 (RPDD). Poisson regressions identified prosthodontic treatment, age, socio‐economic status, diabetes mellitus, mean initial bone loss and aggressive periodontitis as factors significantly contributing to tooth loss. Age, diabetes and non‐compliance contributed to abutment tooth loss. Not considering biomechanical factors, patients with prosthodontic reconstructions under long‐term supportive periodontal therapy were at higher risk for further tooth loss than patients without prostheses. Not only the type of partial denture but also the patient‐related risk factors were associated with abutment tooth loss.