Alistair McGuire

Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study

BACKGROUND Adhesions after abdominal and pelvic surgery are important complications, although their basic epidemiology is unclear. We investigated the frequency of such complications in the general population to provide a basis for the targeting and assessment of new adhesion-prevention measures. METHODS We used validated data from the Scottish National Health Service medical record linkage database to identify patients undergoing open abdominal or pelvic surgery in 1986, who had no record of such surgery in the preceding 5 years. Patients were followed up for 10 years and subsequent readmissions were reviewed and outcomes classified by the degree of adhesion. We also assessed the rate of adhesion-related admissions in 1994 for the population of 5 million people. FINDINGS 1209 (5.7%) of all readmissions (21,347) were classified as being directly related to adhesions, with 1169 (3.8%) managed operatively. Overall, 34.6% of the 29,790 patients who underwent open abdominal or pelvic surgery in 1986 were readmitted a mean of 2.1 times over 10 years for a disorder directly or possibly related to adhesions, or for abdominal or pelvic surgery that could be potentially complicated by adhesions. 22.1% of all outcome readmissions occurred in the first year after initial surgery, but readmissions continued steadily throughout the 10-year period. In 1994, 4199 admissions were directly related to adhesions. INTERPRETATION Postoperative adhesions have important consequences to patients, surgeons, and the health system. Surgical procedures with a high risk of adhesion-related complications need to be identified and adhesion prevention carefully assessed.

The current cost of heart failure to the National Health Service in the UK

We have recently shown that heart failure admission rates continue to increase in the UK — particularly in older age groups. As hospital activity represents the major cost component of healthcare expenditure related to heart failure, this study evaluated the current cost of this syndrome to the National Health Service (NHS) in the UK. We applied contemporary estimates of healthcare activity associated with heart failure to the whole UK population on an age and sex‐specific basis to calculate its cost to the NHS for the year 1995. Direct components of healthcare included in these estimates were hospital admissions associated with a principal diagnosis of heart failure, associated outpatient consultations, general practice consultations and prescribed drug therapy. We also calculated the cost of nursing‐home care following a primary heart failure admission and the cost of hospitalisations associated with a secondary diagnosis of heart failure. Adjusting for probable increases in hospital activity and the progressive ageing of the UK population, we have also projected the cost of heart failure to the NHS for the year 2000. We estimated that there were 988000 individuals requiring treatment for heart failure in the UK during 1995. The ‘direct’ cost of healthcare for these patients was estimated to be £716 million, or 1.83% of total NHS expenditure. Hospitalisations and drug prescriptions accounted for 69 and 18% of this expenditure, respectively. The additional costs associated with long‐term nursing home care and secondary heart failure admissions accounted for a further £751 million (2.0% of total NHS expenditure). By the year 2000, we estimated that the combined total direct cost of heart failure would have risen to £905 million — equivalent to 1.91% of total NHS expenditure. Using well‐validated sets of data, these findings re‐confirm the importance of heart failure as a major public health problem in the UK. The annual direct cost of heart failure to the NHS in 2000 is likely to be of the order of 1.9% of total expenditure — the predominant cost component being hospitalisation.

Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK

Objective: To evaluate the cost of atrial fibrillation (AF) to health and social services in the UK in 1995 and, based on epidemiological trends, to project this estimate to 2000. Design, setting, and main outcome measures: Contemporary estimates of health care activity related to AF were applied to the whole population of the UK on an age and sex specific basis for the year 1995. The activities considered (and costs calculated) were hospital admissions, outpatient consultations, general practice consultations, and drug treatment (including the cost of monitoring anticoagulant treatment). By adjusting for the progressive aging of the British population and related increases in hospital admissions, the cost of AF was also projected to the year 2000. Results: There were 534 000 people with AF in the UK during 1995. The “direct” cost of health care for these patients was £244 million (~€350 million) or 0.62% of total National Health Service (NHS) expenditure. Hospitalisations and drug prescriptions accounted for 50% and 20% of this expenditure, respectively. Long term nursing home care after hospital admission cost an additional £46.4 million (~€66 million). The direct cost of AF rose to £459 million (~€655 million) in 2000, equivalent to 0.97% of total NHS expenditure based on 1995 figures. Nursing home costs rose to £111 million (~€160 million). Conclusions: AF is an extremely costly public health problem.

QALYs : The Basics

The aim of this article is to review the concept of the qualityadjusted life-year (QALY), a widely used measure of health improvement that is used to guide health-care resource allocation decisions. The QALY was originally developed as a measure of health effectiveness for cost-effectiveness analysis, a method intended to aid decision-makers charged with allocating scarce resources across competing health-care programs [1–3]. We refer to this original concept of the QALY, as defined in the early literature, as the “conventional” QALY, recognizing that alternative conceptual models have been proposed, including but not limited to so-called “equity-weighted” QALYs. The US Panel on Cost-Effectiveness in Health and Medicine [4] and the National Institute of Health and Clinical Excellence (NICE) in Britain have both endorsed the conventional QALY for their “reference case,” i.e., a standardized methodological approach to promote comparability in cost-effectiveness analyses of different health-care interventions. In using QALYs, we assume that a major objective of decisionmakers is to maximize health or health improvement across the population subject to resource constraints. The use of QALYs further assumes that health or health improvement can be measured or valued based on amounts of time spent in various health states. The conventional QALY is therefore a valuation of health benefit. We note, however, that decision-makers may also have other objectives such as equity, fairness, and political goals, all of which currently must be handled outside the conventional Special Issue [5] addresses some of these variations on the conventional QALY. The QALY was not initially developed to aid individual patient decision-making, although its use has sometimes been extended into clinical decision analyses for this purpose. The core concept of the conventional QALY is grounded in decision science and expected utility theory. The basic construct is that individuals move through health states over time and that each health state has a value attached to it. Health, which is what we are seeking to maximize, is defined as the value-weighted time—life-years weighted by their quality—accumulated over the relevant time horizon to yield QALYs. Health states must be valued on a scale where the value of being dead must be 0, because the absence of life is considered to be worth 0 QALYs. By convention, the upper end of the scale is defined as perfect health, with a value of 1. To permit aggregation of QALY changes, the value scale should have interval scale properties such that, for example, a gain from 0.2 to 0.4 is equally valuable as a gain from 0.6 to 0.8. States worse than dead can exist and they would have a negative value and subtract from the number of QALYs. These conditions, along with an assumption of risk neutrality over life-years, are sufficient to ensure that the QALY is a useful representation of health state preferences.

Cost effectiveness of an intensive blood glucose control policy in patients with type 2 diabetes: economic analysis alongside randomised controlled trial (UKPDS 41)

Abstract Objective: To estimate the cost effectiveness of conventional versus intensive blood glucose control in patients with type 2 diabetes. Design: Incremental cost effectiveness analysis alongside randomised controlled trial. Setting: 23 UK hospital clinic based study centres. Participants: 3867 patients with newly diagnosed type 2 diabetes (mean age 53 years). Interventions: Conventional (primarily diet) glucose control policy versus intensive control policy with a sulphonylurea or insulin. Main outcome measures: Incremental cost per event-free year gained within the trial period. Results: Intensive glucose control increased trial treatment costs by £695 (95% confidence interval £555 to £836) per patient but reduced the cost of complications by £957 (£233 to £1681) compared with conventional management. If standard practice visit patterns were assumed rather than trial conditions, the incremental cost of intensive management was £478 (-£275 to £1232) per patient. The within trial event-free time gained in the intensive group was 0.60 (0.12 to 1.10) years and the lifetime gain 1.14 (0.69 to 1.61) years. The incremental cost per event-free year gained was £1166 (costs and effects discounted at 6% a year) and £563 (costs discounted at 6% a year and effects not discounted). Conclusions: Intensive blood glucose control in patients with type 2 diabetes significantly increased treatment costs but substantially reduced the cost of complications and increased the time free of complications.

Aggregate health care expenditures and national income: is health care a luxury good?

It is well known that a strong relationship exists between national expenditures on health care and national income. This has been used to suggest that health care is a luxury good, and that factors such as the type of health care delivery system in a country are of little importance in determining expenditure levels. This paper argues that these implications rely upon the application of microeconomic analysis to macroeconomic data, and that this is not appropriate. As well as raising questions about the inferences drawn from previous studies, new empirical evidence is presented which casts some doubts on previous findings. International comparisons are based on Purchasing Power Parity rather than exchange rate conversions, underlining the importance of prices as well as quantities in the relationship, and leading to the conclusion that the aggregate data show health care to be, if anything, a necessity rather than a luxury good.

Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial

Summary Background Ovarian cancer has a poor prognosis, with just 40% of patients surviving 5 years. We designed this trial to establish the effect of early detection by screening on ovarian cancer mortality. Methods In this randomised controlled trial, we recruited postmenopausal women aged 50–74 years from 13 centres in National Health Service Trusts in England, Wales, and Northern Ireland. Exclusion criteria were previous bilateral oophorectomy or ovarian malignancy, increased risk of familial ovarian cancer, and active non-ovarian malignancy. The trial management system confirmed eligibility and randomly allocated participants in blocks of 32 using computer-generated random numbers to annual multimodal screening (MMS) with serum CA125 interpreted with use of the risk of ovarian cancer algorithm, annual transvaginal ultrasound screening (USS), or no screening, in a 1:1:2 ratio. The primary outcome was death due to ovarian cancer by Dec 31, 2014, comparing MMS and USS separately with no screening, ascertained by an outcomes committee masked to randomisation group. All analyses were by modified intention to screen, excluding the small number of women we discovered after randomisation to have a bilateral oophorectomy, have ovarian cancer, or had exited the registry before recruitment. Investigators and participants were aware of screening type. This trial is registered with ClinicalTrials.gov, number NCT00058032. Findings Between June 1, 2001, and Oct 21, 2005, we randomly allocated 202 638 women: 50 640 (25·0%) to MMS, 50 639 (25·0%) to USS, and 101 359 (50·0%) to no screening. 202 546 (>99·9%) women were eligible for analysis: 50 624 (>99·9%) women in the MMS group, 50 623 (>99·9%) in the USS group, and 101 299 (>99·9%) in the no screening group. Screening ended on Dec 31, 2011, and included 345 570 MMS and 327 775 USS annual screening episodes. At a median follow-up of 11·1 years (IQR 10·0–12·0), we diagnosed ovarian cancer in 1282 (0·6%) women: 338 (0·7%) in the MMS group, 314 (0·6%) in the USS group, and 630 (0·6%) in the no screening group. Of these women, 148 (0·29%) women in the MMS group, 154 (0·30%) in the USS group, and 347 (0·34%) in the no screening group had died of ovarian cancer. The primary analysis using a Cox proportional hazards model gave a mortality reduction over years 0–14 of 15% (95% CI −3 to 30; p=0·10) with MMS and 11% (−7 to 27; p=0·21) with USS. The Royston-Parmar flexible parametric model showed that in the MMS group, this mortality effect was made up of 8% (−20 to 31) in years 0–7 and 23% (1–46) in years 7–14, and in the USS group, of 2% (−27 to 26) in years 0–7 and 21% (−2 to 42) in years 7–14. A prespecified analysis of death from ovarian cancer of MMS versus no screening with exclusion of prevalent cases showed significantly different death rates (p=0·021), with an overall average mortality reduction of 20% (−2 to 40) and a reduction of 8% (−27 to 43) in years 0–7 and 28% (−3 to 49) in years 7–14 in favour of MMS. Interpretation Although the mortality reduction was not significant in the primary analysis, we noted a significant mortality reduction with MMS when prevalent cases were excluded. We noted encouraging evidence of a mortality reduction in years 7–14, but further follow-up is needed before firm conclusions can be reached on the efficacy and cost-effectiveness of ovarian cancer screening. Funding Medical Research Council, Cancer Research UK, Department of Health, The Eve Appeal.

Does Hospital Competition Save Lives? Evidence from the English NHS Patient Choice Reforms

Recent substantive reforms to the English National Health Service expanded patient choice and encouraged hospitals to compete within a market with fixed prices. This study investigates whether these reforms led to improvements in hospital quality. We use a difference-in-difference-style estimator to test whether hospital quality (measured using mortality from acute myocardial infarction) improved more quickly in more competitive markets after these reforms came into force in 2006. We find that after the reforms were implemented, mortality fell (i.e. quality improved) for patients living in more competitive markets. Our results suggest that hospital competition can lead to improvements in hospital quality.

Cost of stroke in the United Kingdom

INTRODUCTION this study aims to quantify the annual cost of illness of stroke to the UK economy. METHODS we estimate the cost of stroke from a societal perspective. Direct care costs include diagnosis, inpatient care and outpatient care. Income loss and social benefit payments to stroke patients are accounted for in the indirect cost calculations. Data from South London Stroke Register and a number of other national sources are used. Sensitivity analysis was carried out to account for the variability in the data used. RESULTS the treatment of and productivity loss arising from stroke results in total societal costs of pound 8.9 billion a year, with treatment costs accounting for approximately 5% of total UK NHS costs. Direct care accounts for approximately 50% of the total, informal care costs 27% and the indirect costs 24%. Sensitivity analysis did not alter the estimate of total costs significantly for most of the variables except using of differing prevalence rates. CONCLUSIONS stroke incurs considerable societal costs. Our calculations show a high sensitivity to the underlying prevalence rates used. The findings highlight a need for further economic evaluations to ensure that there is an efficient use of resources devoted to the treatment of this disease.

The West of Scotland coronary prevention study: economic benefit analysis of primary prevention with pravastatin.

Abstract Objective: To estimate the economic efficiency of using pravastatin to prevent the transition from health to cardiovascular disease in men with hypercholesterolaemia. Design: Economic benefit analysis based on data from the West of Scotland coronary prevention study. Treatment specific hazards of developing cardiovascular disease according to various definitions were estimated. Scottish record linkage data provided disease specific survival. Cost estimates were based on extracontractual tariffs and event specific average lengths of stay calculated from the West of Scotland coronary prevention study. Subjects: Men with hypercholesterolaemia similar to the subjects in the West of Scotland coronary prevention study. Main outcome: Cost consequences, the number of transitions from health to cardiovascular disease prevented, the number needed to start treatment, and cost per life year gained. Results: If 10 000 of these men started taking pravastatin, 318 of them would not make the transition from health to cardiovascular disease (number needed to treat, 31.4), at a net discounted cost of £20m over 5 years. These benefits imply an undiscounted gain of 2460 years of life, and thus £8121 per life year gained, or £20 375 per life year gained if benefits are discounted. Restriction to the 40% of men at highest risk reduces the number needed to treat to 22.5 (£5601 per life year gained (undiscounted) and £13 995 per life year gained (discounted)). Conclusions: In subjects without evidence of prior myocardial infarction but who have hypercholesterolaemia, the use of pravastatin yields substantial health benefits at a cost that is not prohibitive overall and can be quite efficient in selected high risk subgroups. Key messages The West of Scotland coronary prevention study showed that pravastatin can prevent cardiovascular disease in men with hypercholesterolaemia So far, reports have deemed this prevention unjustified due to adverse economic implications This analysis, based on data from the West of Scotland coronary prevention study and extensive data from the Scottish record linkage system, shows that using pravastatin in this way is worth considering because of its substantial clinical benefit at a reasonable cost Practitioners must now consider using pravastatin to prevent cardiovascular disease in men with hypercholesterolaemia Increased economic efficiency may be obtained by restricting prevention to patients with additional risk factors