Gillian Hopkins Anderson

Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care

Objectives “Virtual fracture clinics” have been reported as a safe and effective alternative to the traditional fracture clinic. Robust protocols are used to identify cases that do not require further review, with the remainder triaged to the most appropriate subspecialist at the optimum time for review. The objective of this study was to perform a “top-down” analysis of the cost effectiveness of this virtual fracture clinic pathway. Methods National Health Service financial returns relating to our institution were examined for the time period 2009 to 2014 which spanned the service redesign. Results The total staffing costs rose by 4% over the time period (from £1 744 933 to £1 811 301) compared with a national increase of 16%. The total outpatient department rate of attendance fell by 15% compared with a national fall of 5%. Had our local costs increased in line with the national average, an excess expenditure of £212 705 would have been required for staffing costs. Conclusions The virtual fracture clinic system was associated with less overall use of staff resources in comparison to national cost data. Adoption of this system nationally may have the potential to achieve significant cost savings. Cite this article: P. J. Jenkins. Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care. Bone Joint Res 2016;5:33–36. DOI: 10.1302/2046-3758.52.2000506

Public library internet access in areas of deprivation

Draws attention to the key role played by public library Internet access in deprived communities.Highlights the challenges of supporting libraries in their Internet access role.Shows how a range of factors encourage Internet access by library users.Illustrates the diversity of online activities that users engage in. The Internet plays an increasingly central role in the lives of individuals. It enables individuals to engage in social, economic, leisure and entertainment activities including wider access to information. Due to extensive societal use of the Internet, those without access are clearly disadvantaged. They will lack the necessary information to make decisions, forgo the savings from shopping online and limit their opportunities for social interaction. This paper investigates the role that libraries can play in providing free public Internet access. This role is examined within the context of Glasgow, a large post-industrial city in the United Kingdom where Internet adoption is lower than in comparable cities and where a large proportion of its population face a range of socio-economic hardships. Primary data was collected from library users in three areas of deprivation. Our analysis demonstrates the role that libraries play as the provider of public Internet access. It shows that this role is not without its difficulties - inadequate levels of resources have been provided to fulfill the multiple roles that libraries perform in these communities. Libraries enable users to engage in a wide array of online activities, the range of which reflects both the push of government policies and the pull of innovative services.

Exploring the differences in broadband access speeds across Glasgow

Demonstrates how broadband speeds have changed over time.Draws attention to the different broadband speeds that occur across the city.Highlights the range of factors that determine broadband speeds.Links slower broadband speeds with deprived areas. It is widely argued that broadband is beneficial. Higher rates of broadband penetration and adoption are associated with enhanced economic growth, while for individuals accessing the Internet through a broadband connection opens up a range of opportunities to them. However, to enjoy these opportunities users need access to both an Internet connection as well as the possession of a range of skills. As not everyone has access to one or both of these, a range of digital divides have emerged within and between countries.This paper explores one aspect of the digital divides that have emerged, namely, speed. Broadband speeds vary considerably, reflecting many factors such as the technology(s) used, the number of users, the distance of the user from the telephone exchange and so forth. Rather than explore the digital divides that exist between countries, we focus on a single city: Glasgow.Using data from a variety of sources we explore broadband speeds across the city. While broadband speeds have improved across much of Glasgow, this is not true every part of the city. Average speeds vary considerably across the city, with the consequence that the ability to access opportunities online also varies. There is some evidence to suggest that those parts of the city with lower levels of deprivation enjoy higher broadband speeds than areas within Glasgow of higher deprivation levels. Our analysis also found that considerable variations exist between service providers.

Modeling the critical care pathway for cardiothoracic surgery

The west of Scotland heart and lung center based at the Golden Jubilee National Hospital houses all adult cardiothoracic surgery for the region. Increased demand for scheduled patients and fluctuations in emergency referrals resulted in increasing waiting times and patient cancellations. The main issue was limited resources, which was aggravated by the stochastic nature of the length of stay (LOS) and arrival of patients. Discrete event simulation (DES) was used to assess if an enhanced schedule was sufficient, or more radical changes, such as capacity or other resource reallocations should be considered in order to solve the problem. Patients were divided into six types depending on their condition and LOS at the different stages of the process. The simulation model portrayed each patient type’s pathway with sufficient detail. Patient LOS figures were analyzed and distributions were formed from historical data, which were then used in the simulation. The model proved successful as it showed figures that were close to actual observations. Acquiring results and knowing exactly when and what caused a cancellation was another strong point of the model. The results demonstrated that the bottleneck in the system was related to the use of High Dependency Unit (HDU) beds, which were the recovery beds used by most patients. Enhancing the schedule by leveling out the daily arrival of patients to HDUs reduced patient cancellations by 20%. However, coupling this technique with minor capacity reallocations resulted in more than 60% drop in cancellations.

Cost comparison of orthopaedic fracture pathways using discrete event simulation in a Glasgow hospital

Objective Healthcare faces the continual challenge of improving outcome while aiming to reduce cost. The aim of this study was to determine the micro cost differences of the Glasgow non-operative trauma virtual pathway in comparison to a traditional pathway. Design Discrete event simulation was used to model and analyse cost and resource utilisation with an activity-based costing approach. Data for a full comparison before the process change was unavailable so we used a modelling approach, comparing a virtual fracture clinic (VFC) with a simulated traditional fracture clinic (TFC). Setting The orthopaedic unit VFC pathway pioneered at Glasgow Royal Infirmary has attracted significant attention and interest and is the focus of this cost study. Outcome measures Our study focused exclusively on patients with non-operative trauma attending emergency department or the minor injuries unit and the subsequent step in the patient pathway. Retrospective studies of patient outcomes as a result of the protocol introductions for specific injuries are presented in association with activity costs from the models. Results Patients are satisfied with the new pathway, the information provided and the outcome of their injuries (Evidence Level IV). There was a 65% reduction in the number of first outpatient face-to-face (f2f) attendances in orthopaedics. In the VFC pathway, the resources required per day were significantly lower for all staff groups (p≤0.001). The overall cost per patient of the VFC pathway was £22.84 (95% CI 21.74 to 23.92) per patient compared with £36.81 (95% CI 35.65 to 37.97) for the TFC pathway. Conclusions Our results give a clearer picture of the cost comparison of the virtual pathway over a wholly traditional f2f clinic system. The use of simulation-based stochastic costings in healthcare economic analysis has been limited to date, but this study provides evidence for adoption of this method as a basis for its application in other healthcare settings.

Requesting spinal MRIs effectively from primary care referrals

ObjectiveTo define if MRI scans can accurately be requested based on information provided in the primary care referral and, therefore, streamline the patient journey.Summary of background dataThe demand for outpatient spinal appointments significantly exceeds our services’ ability to provide efficient, high-quality patient care. Currently, magnetic resonance imaging (MRI) of the spine is requested following first consultation.MethodsDuring routine vetting of primary care referral letters, three consultant spinal surgeons recorded how likely they thought each patient would be to have an MRI scan. Following the first consultation with the spinal service, the notes of each patient were reviewed to see if an MRI was requested. We measured the positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity of ordering MRI scans based on primary care referral letters.Results149 patients were included [101 females, 48 males, mean age 49 (16–87)]. There were 125 routine, 21 urgent, and 3 ‘urgent-suspected cancer’ referrals. The PPV of ordering MRIs before first consultation was 84%, NPV was 56% with the sensitivity and specificity being 82 and 59%, respectively. Ordering MRIs during initial vetting could shorten the patient journey with potential socioeconomic benefits.ConclusionsMRI scans can be effectively ordered based on the information provided by the primary care referral letter. Requesting MRI scans early in the patient journey can save considerable time, improve care, and deliver cost savings.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Quantifying intra-organisational risks: an analysis of practice-theory tensions in probability elicitation to improve technical risk management in an energy utility

Assessing the likelihood of future events is core to technical risk management at Scottish Power Generation. Events can include failures resulting in unavailability of key assets or incidents impacting staff safety or the environment. Eliciting probabilities from engineers to quantify the likelihood of future, uncertain events is challenging given the diversity of assets across the multiple, heterogeneous power plants operated by Scottish Power Generation. Such probability assessments inform investment decisions intended to manage technical risks and support regulatory compliance. Through interviews with engineers, we reveal the opportunities for heuristics and bias that explain some of the historical disparities in assessments intuitively evident to risk managers. We propose better ways of obtaining judgemental probability assessments based on a study involving engineers and a control group of post-experience students. We find that the choice of scale descriptors impacts the probability values of defined events as judged by engineers. Consequently, we suggest changes to the risk management system, including new design features to better frame and capture probability assessments. As a consequence of our study, the technical risk management process is being enhanced in a number of ways, including the creation of a single organisational-wide framework, clearer guidelines and better knowledge management.