Potential for cost economies in guiding therapy in patients with metastatic breast cancer.

Therapeutic response in patients with advanced breast cancer is conventionally assessed with reference to criteria devised by the International Union Against Cancer. Evidence to date suggests, however, that assessments of equivalent quality may be obtained at lower cost from the use of serum markers. The paper presents estimates of potential cost savings resulting from the use of serum markers in place of conventional assessment and argues that the size of these savings merits the establishment of a randomised controlled trial.     

General practitioner fundholding and prescribing expenditure control. Evidence from a rural English health authority

In April 1991, the fundholding and indicative prescribing schemes introduced budgets for expenditure on prescribed drugs into UK general practice. Although both schemes were designed to be equally effective at containing prescribing-cost inflation, several studies suggest that expenditure growth has been lower in fundholding practices, compared with nonfundholding practices. This study attempts to ascertain how fundholding practices control their expenditure by examining data from a rural English health authority for the financial year 1993 to 1994. The fundholding practices sampled were found to control their expenditure through: (i) reduced overprescribing; (ii) using fewer drugs that have limited clinical value; (iii) substituting similar, but less expensive, drugs; (iv) more generic prescribing; and (v) appropriate use of expensive preparations. However, whether the cost differential between fundholding and nonfundholding practices is sustained in future years will depend upon: (i) the ability of fundholding practices to generate further savings; (ii) the characteristics of the practices that enter the fundholding scheme in subsequent waves; (iii) the way in which the scheme is organised; and (iv) the level at which budgets are set.     

The cost of screening for colorectal cancer.

STUDY OBJECTIVE--The aim was to make projections of the likely costs and yield resulting from the implementation of a faecal occult blood screening programme for colorectal cancer. DESIGN--Cost and clinical data were derived from the MRC colorectal screening trial currently in progress in Nottingham, UK. SETTING--The above data were used as the basis for modelling the likely implications were the trial to be reproduced as a screening programme within a "typical" family practitioner committee area. MAIN RESULTS--For an average family practitioner committee area with a target population of 75,000 subjects aged 50-74 years, the initial screening round might be expected to detect 85 cancers at a total cost of approximately 250,000 pounds. This represents a cost per cancer detected of 2700 pounds and a cost per person screened of approximately 5 pounds. For subsequent screening rounds, total costs might be expected to fall although average costs are likely to remain approximately constant. CONCLUSIONS--The model is successful in generating "order of magnitude" estimates for the costs of implementation of a screening programme for colorectal cancer. As benefit estimates are not yet available, however, no cost-effectiveness analysis can be undertaken at this stage. In general, sensitivity analyses reveal that programme costs are more sensitive to changes in clinical variables, especially detection and compliance rates, than they are to variations in the costs of resource inputs. A screening programme with a more elaborate protocol than that currently employed in the Nottingham trial will entail considerable cost increases.     

Selection bias in GP fundholding

This paper uses a logistic regression model based on 1993 data for general practices in a single Family Health Services Authority (Lincolnshire) to analyse the differences in characteristics between existing fundholding (up to and including wave three) and non-fundholding practices. A high degree of classification accuracy is obtained. Fundholders are revealed to be more likely than non-fundholders to meet a number of the various quality criteria laid down by central government following the 1990 National Health Services Act, for example, with respect to prescribing cost control, minor surgery and cervical screening uptake. The model is employed to forecast the fourth wave of fundholding and poor predictions suggest the existence of a structural break in the characteristics of fundholders between those in the first three waves and those of wave four. The evidence presented also supports the existence of selection bias in the first three waves of fundholding, although further logistic regression analysis reveals a form of such bias in the fourth wave also.     

Responsiveness of the EQ-5D to HADS-identified anxiety and depression

Rationale  The use of generic measures of health-related quality of life enables cost effectiveness comparisons of different health care interventions to be made. Nevertheless, there exists a concern that generic instruments may be insufficiently sensitive to detect the differences or changes in outcome identified by condition-specific instruments. This paper compares the psychometric properties of the EQ-5D generic instrument with a widely used specific measure of distress, the Hospital Anxiety and Depression Scale (HADS).
Method  The analysis was based on data obtained from a large sample of women ( n  = 3119) with low-grade cervical cytological abnormalities detected at routine screening. These women completed EQ-5D and HADS questionnaires at recruitment and at 12 months thereafter. We examined the strength of association between HADS-determined severity of distress and EQ-5D scores at recruitment and between changes in severity and in scores over time.
Results  A higher likelihood of HADS-identified anxiety and/or depression was associated with significantly lower EQ-5D index and visual analogue scores. Over time, the EQ-5D score rose significantly when the likelihood of an individual representing a HADS-defined anxiety and/or depression case decreased.
Conclusion  We conclude that the EQ-5D has shown itself to be responsive to differing degrees of HADS-assessed distress, although generalization beyond the UK context requires further investigation.     

Prevention of mother-to-child transmission of HIV in developing countries: recommendations for practice. The Ghent International Working Group on Mother-To-Child Transmission of HIV

OBJECTIVES: Different approaches to prevent mother-to-child transmission of HIV are being evaluated in developing countries. The first trials using a short regimen of zidovudine have been successful in Thailand, C?te d'Ivoire and Burkina Faso. International and local strategies are now being considered. The Ghent International Working Group on Mother-to-Child Transmission of HIV developed public health policy options to integrate these interventions into basic and maternal and child health (MCH) services. METHODS: The following tasks were undertaken: a critical review of randomized trials; an international pooled analysis of late postnatal transmission of HIV through breastfeeding; a review of the cost-effectiveness and cost-benefit of antiretroviral prophylaxis; a feasibility assessment of preventive strategies, including a postal survey on HIV voluntary counselling and testing (VCT) of pregnant women; the identification of requirements and research priorities for prenatal, obstetric and paediatric care. These projects provided the background for a three-day workshop in Ghent, Belgium, in November 1997. Conclusions were further refined, based on 1998 research findings. RESULTS: A summary of relevant evidence and ten public health recommendations are reported. VCT for pregnant women, a short regimen of zidovudine together with alternatives to breastfeeding currently represent the best option to reduce vertical transmission in most developing countries. The primary goal of the integrated package supporting these interventions is to alleviate overall maternal and infant morbidity and mortality. CONCLUSION: Prevention of mother-to-child transmission of HIV should now be considered for integration into basic health and MCH services of selected countries, with the involvement of governments and donor agencies.     

Measuring concentration in primary care

There is evidence that patient choice and the quality of service delivery in primary care can be influenced by the organisation and structure of provision at the local level. However, the formal measurement of structure in primary care has yet to be undertaken. Using data for Coventry, standard concentration measures are estimated, which show that concentration varies considerably across the city and tends to be higher in areas of lower deprivation. Assuming that patient choice is an important consideration in health care planning, concentration measurement may provide a useful tool for health authorities in making decisions about GP numbers, practice mergers and re‐location. This revised version was published online in July 2006 with corrections to the Cover Date.     

Correspondence between EQ-5D health state classifications and EQ VAS scores

Background  

The EQ-5D health-related quality of life instrument comprises a health state classification followed by a health evaluation using a visual analogue scale (VAS). The EQ-5D has been employed frequently in economic evaluations, yet the relationship between the two parts of the instrument remains ill-understood. In this paper, we examine the correspondence between VAS scores and health state classifications for a large sample, and identify variables which contribute to determining the VAS scores independently of the health states as classified.     

Eliciting relative preferences for two methods of colorectal cancer screening

Two methods of mass population screening for colorectal cancer - faecal occult blood testing and sigmoidoscopy - have been the subject of randomized controlled trials in the UK. A national screening programme is currently under consideration and the choice of screening method remains open. To be successful, a programme will require high levels of uptake, and uptake is likely to depend upon subjects' attitudes towards the screening method introduced. Although a preferred screening method has already been identified from a questionnaire survey, we undertook a further interview study (n = 106), with a view to comparing the results of two different approaches to eliciting public preferences. In comparison with the questionnaire study, a higher proportion of interview subjects stated a preference. Interview subjects were generally more favourably disposed towards sigmoidoscopy, excepting those with previous experience. Compared with the questionnaire survey, the interviews provided richer information on the reasons for preferences offered. Individual preferences were evidently subjective and dependant on attitudes towards a variety of method characteristics, such as discomfort, convenience and perceived sophistication. Characteristics such as age and low income, which had predicted preferences in the questionnaire study, predicted preferences in the interview study also. The difference between the results obtained by the different elicitation techniques can be explained in terms of the differential provision of information and sample selection. Conclusions made about public preferences are likely to depend on the technique employed in eliciting them.     

Willingness-to-pay for pediatric cochlear implantation

OBJECTIVE: This paper presents the results of the first willingness-to-pay (WTP) study to be undertaken on cochlear implantation. It aims to measure the values parents place on the UK having a pediatric cochlear implantation (PCI) programme. METHODS: Face-to-face semi-structured interviews were conducted with parents of children from the Nottingham Pediatric Cochlear Implant programme, whom had been implanted for a period ranging from 1 month to 13 years. Parents willingness-to-pay for the UK to have a pediatric cochlear implantation programme were elicited using a bidding process question format and via a discrete choice question. To see if income was a significant determinant of willingness-to-pay an analysis of variance (ANOVA) was undertaken in the statistical package SPSS version 10. RESULTS: Two hundred and sixteen parents were interviewed over the period July 2001-August 2002, representing over 130h of interviewing. The mean and median willingness-to-pay values elicited were UK pound 127 and 50 per month, respectively (UK pound 2001/2002). Willingness-to-pay was positively related to income (P<0.020). When the income constraint was removed, 99% of parents choose the implant over having the money the implant would cost to spend in some other way to benefit their child. CONCLUSIONS: Parents of implanted children were willing to pay substantial monthly amounts for pediatric cochlear implantation. Most parents saw no alternative to pediatric cochlear implantation that could improve their child's quality of life to the same extent. Willingness-to-pay was sensitive to income as expected suggesting that the values elicited are both valid and influenced by a respondent's budget constraint.