A. S. St Leger

Are GP practice prescribing rates for coronary heart disease drugs equitable? A cross sectional analysis in four primary care trusts in England

Study objective: To analyse the associations between proxies of healthcare need and GP practice prescribing rates for five major coronary heart disease (CHD) drug groups. Design: Cross sectional secondary analysis. Setting: Four primary care trusts (PCTs 1–4) in the north west of England, encompassing 132 GP practices. Results: Prescribing rates were generally positively associated with the percentage of patients aged 55–74 years and PASS-PUs (regionally specific prevalence, age, and sex standardised prescribing units). However, the percentage of patients aged over 75 years showed a lack of association with prescribing rates in all PCTs other than PCT2. Correlations with the proportion of South Asian patients were generally negative, particularly in PCT2, PCT4, and the combined dataset. There was a general lack of association with deprivation proxies and SMRs for CHD, although there were negative associations with both variables in PCT4 and the combined dataset. Scatter plots showed that GP practices with similar prescribing rates had widely differing levels of comparative healthcare need, and GP practices with similar levels of healthcare need had widely differing prescribing rates. Conclusion: GP prescribing rates in some PCTs were negatively associated with proxies of healthcare need based on patient age (patients aged over 75 years), ethnicity, levels of deprivation, and SMRs for CHD. As such, this study suggests that prescribing rates in these PCTs may be inequitable as they are not positively associated with healthcare need. This study may form the baseline for further studies to assess the effectiveness of the NSF for CHD in reducing the inequities in prescribing rates.

Screening for abdominal aortic aneurysm: a computer assisted cost-utility analysis.

OBJECTIVESnTo evaluate the effects of introducing routine ultrasonic screening for the identification and elective surgical treatment of abdominal aortic aneurysms (AAA) at high risk of rupture in the U.K. population of men aged 65-74 years.nnnDESIGNnA computer assisted simulation of an AAA screening programme. The simulation incorporated assumptions gleaned from the literature about the epidemiology of AAA and the costs of screening. In addition, up-to-date costings based on recent Manchester (U.K.) vascular surgery experience are used.nnnSETTINGnA dialogue between National Health Service commissioners and providers to explore the feasibility and desirability of introducing AAA screening. CHIEF OUTCOME MEASURE: Cost per quality adjusted life year (QALY) gained.nnnMAIN RESULTSnThe absolute cost (circa 1992/3) per QALY gained from screening for and treating aneurysms of > or = 6 cm in diameter of pounds 1500 (benefit not discounted). Offsetting current treatment costs of ruptured aneurysms gives a net additional cost per QALY of pounds 1300. Screening and treating aneurysms of > or = 5 cm leads to a cost per QALY gained exceeding pounds 20000. The findings are robust under sensitivity analysis.nnnCONCLUSIONSnRoutine screening for AAAs of size > or = 6 cm compares favourably in terms of cost per QALY gained with services such as breast and cervical cancer screening.

Clinical and economic choices in anaesthesia for day surgery: a prospective randomised controlled trial.

Summary We compared the cost‐effectiveness of general anaesthetic agents in adult and paediatric day surgery populations. We randomly assigned 1063 adult and 322 paediatric elective patients to one of four (adult) or two (paediatric) anaesthesia groups. Total costs were calculated from individual patient resource use to 7u2003days post discharge. Incremental cost‐effectiveness ratios were expressed as cost per episode of postoperative nausea and vomiting (PONV) avoided. In adults, variable secondary care costs were higher for propofol induction and propofol maintenance (propofol/propofol; pu2003<u20030.01) than other groups and lower in propofol induction and isoflurane maintenance (propofol/isoflurane; pu2003<u20030.01). In both studies, predischarge PONV was higher if sevoflurane/sevoflurane (pu2003<u20030.01) was used compared with use of propofol for induction. In both studies, there was no difference in postdischarge outcomes at Dayu20037. Sevoflurane/sevoflurane was more costly with higher PONV rates in both studies. In adults, the cost per extra episode of PONV avoided was £296 (propofol/propofol vs. propofol/ sevoflurane) and £333 (propofol/sevoflurane vs. propofol/isoflurane).

Interventions to increase breast screening uptake: do they make any difference?

Background Breast screening has an important role in improving survival from breast cancer through early detection and treatment. Increasing uptake of screening in areas of low uptake is important in improving the effectiveness of the national screening programme. This review looks at which initiatives to boost uptake have been successful. Objective To evaluate the effectiveness of the different interventions to increase breast screening uptake. Method A systematic review of interventions to promote breast screening uptake was undertaken. Studies were included if uptake was used as an outcome measure of the intervention and if relevant to the UK screening programme. Results Twenty eight studies were found among 25 citations. Interventions were grouped into “person directed”, “system directed”, “social network directed”, and “multistrategy” categories. Most were person directed. These interventions were more likely to be effective in boosting uptake, be simple in design, and to have been evaluated by a randomised trial design. Evidence of effectiveness in the other groups is limited both by the number of studies and the study designs. A summary of the interventions reviewed is presented. Conclusions Simple, brief, and effective interventions exist to boost breast screening uptake. More complicated approaches are not necessarily any more effective. These findings also have implications for other population based screening programmes of the future. In inner city areas the best approach to raising uptake rates is likely to be multistrategy.

The effect of anaesthetic agents on induction, recovery and patient preferences in adult day case surgery: a 7-day follow-up randomized controlled trial.

Background and objective: To compare induction, pre‐ and post‐discharge recovery characteristics and patient preferences between four anaesthetic regimens in adult day‐surgery. Methods: Randomized controlled trial. In all, 1158 adults assigned to: propofol induction and maintenance, propofol induction with isoflurane/N2O, or sevoflurane/N2O maintenance, or sevoflurane/N2O alone. We prospectively recorded induction and pre‐discharge recovery characteristics, collected 7‐day post‐discharge recovery characteristics using patient diaries and patient preferences by telephone follow‐up. Results: Recruitment rate was 73% ‐ of the 425 refusals, 226 were not willing to risk a volatile induction. During induction, excitatory movements and breath holding were more common with sevoflurane only (P < 0.01). Injection pain and hiccup were more common with propofol induction (P < 0.01). In the recovery room and the postoperative ward, both nausea and vomiting were more common with sevoflurane only (P < 0.01). This difference disappeared within 48 h. There was no difference between groups in the mental state on awakening, recovery time, time to discharge or overnight admissions; then was also no difference in pain between the four groups for each of the seven postoperative days (P < 0.01), nor any differences in concentration or forgetfulness. Patients took 6.5 days (95% CI: 6.0‐7.0, n = 693) to resume normal activities. Patients who received sevoflurane only were more likely to recall an unpleasant induction and least likely to want the same induction method again (P < 0.01). Conclusion: Differences in outcome between the four regimens are transient; sevoflurane is not an ideal sole agent for adult day case anaesthesia and, in this setting, patients base their preferences for future anaesthetics on the method of induction.

Developing prevalence-based prescribing units for analysing variations in general practitioner prescribing: a case study using statins

Objective:u2002 To develop regionally specific prevalence‐, age‐ and sex‐standardized prescribing units (PASS‐PUs) and to relate these to statin prescribing.

Analysis of secular trends in surgery for glue ear in the North Western Region (1975–1984)

Hospital Activity Analysis (HAA) data relating to operations for glue ear and tonsillectomy performed on residents of the North Western Region, aged 0-9 years during the period 1975-1984 were studied. The rate of surgery for glue ear has risen from 45/10,000 to 107/10,000 representing an increase of 137 per cent. The tonsillectomy rate by comparison has undergone a more modest increase of 19 per cent. The study casts doubt on a vacuum effect, as has been argued by Black. Marked variation in rates of surgery between Districts in the Region were noted, and the possible explanations discussed. A review of the literature revealed considerable controversy concerning the management of glue ear and the need for a definitive trial is highlighted.