Karen Bloor

Lessons from international experience in controlling pharmaceutical expenditure. I: Influencing patients.

This is the first of three papers to review international policies to control spending on drugs and improve the efficiency of drug use. Policies can target three main groups: patients, prescribing doctors, and the drugs industry. In this paper we examine policies aimed at patients, particularly restrictions on reimbursement (such as prescription charges). Rigorous experimental and quasi-experimental studies suggest that policies to limit the level of reimbursement of drugs reduce the use of essential as well as non-essential drugs and may do more harm than good.

Challenges for the National Institute for Clinical Excellence

So far NICE has focused on evaluating new technologies rather than existing ones. But this approach is creating inflationary pressure that the NHS cannot afford

Lessons from international experience in controlling pharmaceutical expenditure. III: Regulating industry.

This is the third of three papers that review international policies to control spending on drugs and to improve the efficiency of drug use. This paper reviews policies regulating the supply of drugs, particularly licensing and reimbursement controls, price and profit regulation. Price and profit controls contain few incentives for improving cost effective use of drugs, and focus on cost containment and profitability of domestic industry. Carefully monitored economic evaluation could lead to improvements in efficiency and benefits to patients and the health care system.

Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET)

Objective To compare the cost effectiveness of nurses and doctors in performing upper gastrointestinal endoscopy and flexible sigmoidoscopy. Design As part of a pragmatic randomised trial, the economic analysis calculated incremental cost effectiveness ratios, and generated cost effectiveness acceptability curves to address uncertainty. Setting 23 hospitals in the United Kingdom. Participants 67 doctors and 30 nurses, with a total of 1888 patients, from July 2002 to June 2003. Intervention Diagnostic upper gastrointestinal endoscopy and flexible sigmoidoscopy carried out by doctors or nurses. Main outcome measure Estimated health gains in QALYs measured with EQ-5D. Probability of cost effectiveness over a range of decision makers’ willingness to pay for an additional quality adjusted life year (QALY). Results Although differences did not reach traditional levels of significance, patients in the doctor group gained 0.015 QALYs more than those in the nurse group, at an increased cost of about £56 (€59,

Effect of physicians’ gender on communication and consultation length: a systematic review and meta-analysis

78) per patient. This yields an incremental cost effectiveness ratio of £3660 (€3876,

Impact of NICE guidance on laparoscopic surgery for inguinal hernias: analysis of interrupted time series

5097) per QALY. Though there is uncertainty around these results, doctors are probably more cost effective than nurses for plausible values of a QALY. Conclusions Though upper gastrointestinal endoscopies and flexible sigmoidoscopies carried out by doctors cost slightly more than those by nurses and improved health outcomes only slightly, our analysis favours endoscopies by doctors. For plausible values of decision makers’ willingness to pay for an extra QALY, endoscopy delivered by nurses is unlikely to be cost effective compared with endoscopy delivered by doctors. Trial registration International standard RCT 82765705

Regulating the pharmaceutical industry.

Objective Physician gender may be a source of differences in communication between physicians and their patients, which may in turn contribute to patient satisfaction and other outcomes. Our aim was to review systematically research on gender differences in the length, style and content of communication with patients. Methods Seven electronic databases were searched from inception to September 2010 with no language restrictions (included MEDLINE; PsychINFO; EMBASE; CINAHL; Health Management Information Consortium; Web of Science; and ASSIA). ‘Grey’ literature was also searched. Data extraction and quality assessment was carried out in accordance with Cochrane Collaboration guidelines by at least two reviewers. The review uses mainly narrative synthesis due to the heterogeneous nature of the studies, with only data on consultation length being pooled in a random effects generic inverse variance meta-analysis. Results Searches yielded 6412 articles, of which 33 studies fulfilled the inclusion criteria. Studies were heterogenous and of mixed quality. Conflicting results are reported for many communication variables. There is some evidence that female physicians adopt a more partnership building style and spend on average 2.24 min longer with patients per consultation (95% CI 0.62–3.86) than their male colleagues. Conclusions Greater patient engagement by female doctors may reflect a more patient-centred approach, but their longer consultation times will limit the number of consultations they can provide. This has implications for planning and managing services.

Health-service costs of pediatric cochlear implantation: multi-center analysis

After the introduction of Bassinis procedure in the late 19th century, methods of repairing hernias changed little until the 1990s, when synthetic mesh and laparoscopic methods arrived.1 In contrast to the open mesh technique, laparoscopic surgery remains uncommon. In January 2001, the National Institute for Clinical Excellence (NICE) issued guidance that stated, “For repair of primary inguinal hernia, open [mesh] should be the preferred surgical procedure.”2 We describe patterns of surgical repair of inguinal hernias and assess the impact of NICEs guidance. We found 217 000 cases with a primary procedure code for primary surgery for an inguinal hernia from the hospital episode statistics database for England from April 1998 to December 2001. Of these, secondary procedure codes for minimal access surgery identified 8960 (4.1%) cases in which surgery was laparoscopic. We …

Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET) - art. no. b231

The pharmaceutical price regulation scheme1 is a voluntary agreement between Britains Department of Health and the Association of the British Pharmaceutical Industry in which companies negotiate generous target profit rates from sales of drugs to the NHS (17-21% rate of return on investment in research and development). The schemes objectives are to secure the provision of safe and effective medicines to the NHS at reasonable prices; to promote a strong pharmaceutical industry in Britain; and to encourage the efficient and competitive development and supply of medicines worldwide.1 The scheme was renewed in 1993 for five years and is currently under review. Although the scheme has been successful in helping to maintain the British pharmaceutical industry, its objectives conflict, and the way the scheme operates pays little regard to other health policy objectives. As the price of renegotiation, the government should request changes to the scheme, to minimise the inherent conflicts and to ensure that the scheme supports other policies. There is considerable evidence of the schemes success at achieving a strong industry.2 However, drug prices in Britain are …

Gender and variation in activity rates of hospital consultants

OBJECTIVE Pediatric cochlear implantation (CI) entails surgery followed by lifetime maintenance, and hence incurs both initial and ongoing costs. Previous assessments of these costs were either undertaken early in the evolution of services, or were based on single hospitals, or estimated costs largely from hospital charges. The aim was to overcome these limitations by conducting a multi-center evaluation of the costs of providing unilateral CI to children in the United Kingdom (UK). METHODS Annual numbers of implantations in all UK pediatric CI programs were monitored prospectively from 1991. Resource use was measured in 12 programs in 1998/1999 and retrospectively back to the year of inception of each program. The profile of outpatient and outreach visits was assessed in the 12 programs. Together these variables were used to estimate health-service costs for four phases of management: pre-operative assessment, implantation, tuning, and subsequent maintenance, using economic micro-costing methods. Costs were subsequently estimated for all children implanted in 1998/1999 (N=199) and were aggregated over 1, 15, and 73 years following implantation. To assess the robustness of cost estimates, parameter values were varied over plausible ranges and costs re-estimated. Total UK health-service costs were also estimated. All costs are presented in euros (1=US dollars 0.98= pound 0.65, 1st July 2002), inflated to 2000/2001 financial-year levels, and discounted at 6% per annum. RESULTS Per-child average costs were 42972 (1-year), 73763 (15-years), and 95034 (73-years). Cost estimates were not overly sensitive to the value of any one cost component nor to the relative cost of outpatient and outreach visits. When these parameters were varied, costs ranged between 30000 and 47000 (1-year), 61000 and 83000 (15-years), and 82000 and 108000 (73-years). The total UK health-service cost of unilateral pediatric CI was estimated to be 14 million in 2000/2001 and is predicted to rise to 23 million in 2015/2016, if the present model of service-delivery continues. The cost of maintaining implanted children was estimated to account for 22% of the total in 2000/2001 and is predicted to rise to 63% by 2015/2016. CONCLUSIONS Ongoing costs of maintaining implanted children and their implant systems are significant and should be factored into resource-allocation decisions.