National Health Service Setting Research Articles

Cost-Minimization Analysis of the Treatment of Patients With Metastatic Colorectal Cancer in Greece

BackgroundIn 2008, colorectal cancer was the fourth most common cause of cancer-related death worldwide. Monotherapy with monoclonal antibodies directed against the epidermal growth factor receptor, such as cetuximab and panitumumab, has recently been introduced in the management of metastatic colorectal cancer (mCRC) patients. ObjectiveThe aim of this study was to conduct a cost-minimization analysis comparing panitumumab with cetuximab in the treatment of patients with epidermal growth factor receptor–expressing mCRC with nonmutated (wild-type) Kirsten rat sarcoma viral oncogene homolog in Greece. The perspective of analysis was that of payers (Social Security Sickness Fund) and the country's National Health Service (NHS). MethodsThe model was designed to contain probabilistic parameters to account for uncertainty and variation in these parameters. All resources consumed in local hospitals in the management of patients in each case were evaluated. Two analyses were performed: 1 evaluating cost per milligram and another evaluating cost per vial. ResultsFrom a payer perspective, the mean 20-week total cost per patient for panitumumab and cetuximab was: (1) per-milligram analysis: €16,349 and €18,242, respectively; and (2) per-vial analysis: €18,808 and €19,701. From the NHS perspective, the mean total costs per patient were slightly higher; however, the use of panitumumab was associated with a 17.7% and 12.4% cost reduction in per-milligram and per-vial analysis, respectively. The results of probabilistic models confirmed those of the deterministic analyses. ConclusionIn the Greek NHS and Social Security Sickness Fund setting, panitumumab monotherapy potentially constitutes a cost-saving option (versus cetuximab monotherapy) in the management of patients with mCRC and no mutation of Kirsten rat sarcoma viral oncogene homolog.

Body work in assisted conception: exploring public and private settings

Body work has been foregrounded in recent sociological writings on health and social care, particularly the emotional labour of patient care. In this article I explore the social and emotional dimensions of body work in assisted conception in private and public National Health Service (NHS) clinics. Drawing on an ethnographic study, I explore how tensions around bodily attributes, treatment costs, clinic performance and the extent of consumer sovereignty were managed in decisions about who to treat and in what manner. In NHS settings, body work involved efforts to standardise and constrain bodies in line with an ethics of justice that included the co-construction of protocols and performance measurement and a strong emphasis upon teamwork and influencing the behaviour of the sector as a whole. In contrast, body work in private settings was more overtly organised around an ethos of individual consumption that emphasised bespoke treatment together with an active critique of the regulator, based on a strong entrepreneurial ethos. Emotional labour in private settings was also more overt. I conclude by exploring the implications of my analysis for the study of assisted conception, the sociology of body work and the further marketisation and deregulation of medicine.

Lumbosacral prolotherapy: a before-and-after study in an NHS setting

AbstractObjectiveTo evaluate the efficacy of prolotherapy in the lumbosacral spine of patients with symptomatic apparent ligamentous laxity, in a National Health Service (NHS) setting.MethodA two-centre, before-and-after study of 197 consecutive patients followed up for a year using Visual Analogue Scales and Oswestry Disability Index.ResultsAllowing for minor differences in approach and population demographics 91% of respondents were better or the same after 12 months.ConclusionsThis study looked at the use of prolotherapy in patients who had failed to respond to conservative approaches including spinal manipulation and physiotherapy in NHS back pain clinic settings. These patients had longstanding and often severe pain and disability. Previous trials of prolotherapy have produced conflicting results but all had methodological problems. The results of this study promote the case for a new NHS-based randomized controlled trial of prolotherapy in the syndrome described as ligamentous laxity.

Free to talk about violence: A description of art therapy with a male service user in a low secure unit

A low secure unit is a challenging environment in which to work. This article charts the progress, development and role of art therapy within a low secure ward for male clients within a National Health Service (NHS) setting. Through a case example, it will describe how the image is central to the therapeutic process of treating offending behaviour. I will also explore how art making can build safety and security in different ways through selected examples of art images and accompanying dialogue. The dialogue is selected from a service user report and my own therapist report. Since the 1980s and '90s low secure units have grown around the country. They are subject to continuous public scrutiny, making them tense environments in which to work. I hope that my observations about practice will be of interest to other art therapists working in forensic and related settings. Art therapy approaches in forensic settings vary in their treatment approach to offending behaviour. I will describe the context in detail and explore the practice through a case example.

Introducing the CORE-OM in a South African Context: Validation of the CORE-OM using a South African Student Population Sample

The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) was originally introduced as a standardised, practice-based evidence tool for generating effectiveness data by practitioners within the context of routine clinical practice in the United Kingdom's National Health Service (NHS) settings. Following wide application across UK NHS sites the CORE-OM has proven to be a pragmatic measure of both a) gross psychological distress and b) the effectiveness of psychotherapy interventions across client populations, presenting problems, clinical settings and therapy models. However in order for South Africa to benefit from this tool, the CORE-OM must be applicable within a South African context. This requires its validation within South African populations. The aim of this article is to demonstrate the cross-cultural validity of the CORE-OM, using a South African student population sample and in so doing to provide preliminary referential data for use in interpreting CORE-OM scores within English-medium, South African University student counselling centre contexts.

Cost-effectiveness of the implantable HeartMate II left ventricular assist device for patients awaiting heart transplantation

Left ventricular assist devices (LVADs) are being proposed as a life-saving therapeutic alternative to conventional medical management for people with end-stage heart failure awaiting transplantation. However, cost-effectiveness assessments of first-generation LVADs have not been encouraging. The cost-effectiveness of the enhanced second-generation LVAD HeartMate II (Thoratec, Pleasanton, CA) is estimated here. A probabilistic Markov model was developed to extrapolate survival, utility, and resource use over the total lifetime of a hypothetic cohort of patients with end-stage heart failure under the 2 competing therapeutic strategies, using the most robust and recently published evidence about their performance. Cost data are based on UK activity to consider reimbursement in the UK National Health Service setting. HeartMate II had a mean cost per quality-adjusted life-year (QALY) of £258,922 ($414,275). The sensitivity analysis showed that 2 factors mainly explain why HeartMate II is not a cost-effectiveness strategy as a bridge-to-transplant: (1) the survival of heart transplant candidates treated conventionally while on the waiting list has significantly improved in recent years, and (2) the high acquisition cost of the device, £94,200 ($150,720). Although HeartMate II LVAD implantation significantly increases survival compared with conventional medical management, it does not provide good value for the money spent according to established thresholds of cost-effectiveness in the UK. HeartMate II is unlikely to become cost-effective unless the additional survival gained by its use raises and/or the device is given free of charge. Therefore, its implantation to transplant candidates lacks justification in terms of cost-effectiveness.

Family-based behavioural treatment of childhood obesity in a UK national health service setting: randomized controlled trial

BackgroundThe best outcomes for treating childhood obesity have come from comprehensive family-based programmes. However there are questions over their generalisability.ObjectiveTo examine the acceptability and effectiveness of ‘family-based behavioural treatment’ (FBBT) for childhood obesity in an ethnically and socially diverse sample of families in a UK National Health Service (NHS) setting.MethodsIn this parallel group, randomised controlled trial, 72 obese children were randomised to FBBT or waiting list control. Primary outcomes were body mass index (BMI) and BMI standard deviation scores (SDS). Secondary outcomes were weight, weight SDS, height, height SDS, waist, waist SDS, fat mass index, fat free mass index, blood pressure, and psychosocial measures. Outcomes were assessed at baseline and post-treatment, with analyses on the 6 month data done on an intent-to-treat (ITT) basis. Follow-up anthropometric data were collected at twelve months for the treatment group.ResultsITT analyses included all children with baseline data (n=60). There were significant BMI SDS changes (p<0.01) for the treatment and control groups of −0.11 (0.16) and −0.10 (1.6). The treatment group showed a significant reduction in systolic blood pressure (−0.24 (0.7), p<0.05) and improvements in quality of life and eating attitudes (p<0.05), with no significant changes for the control group. However the between-group treatment effects for BMI, body composition, blood pressure and psychosocial outcomes were not significant. There was no overall change in BMI or BMI SDS from 0-12 months for the treatment group. No adverse effects were reported.ConclusionsBoth treatment and control groups experienced significant reductions in level of overweight, but with no significant difference between them. There were no significant group differences for any of the secondary outcomes.

Development and delivery of an exercise intervention for rheumatoid arthritis: Strengthening and stretching for rheumatoid arthritis of the hand (SARAH) trial

This paper describes the development and implementation of a hand exercise intervention for rheumatoid arthritis (RA) as part of a large multi-centred randomised controlled trial in a UK National Health Service (NHS) setting. Participants are eligible if diagnosed with RA according to American College of Rheumatology criteria, have a history of disease activity, functional deficit or impairment in the hand and/or wrist, and have been on a stable medication regime for at least 3 months. The intervention development was informed by the current evidence base, published guidelines, clinician and expert opinion, and a pilot study. The exercise programme targets known, potentially modifiable physical impairments of the hand with 5 exercise sessions and a home exercise component over a 12 week period. The intervention will be provided to 240 participants along with usual care. A further 240 will receive usual care only as part of the control arm. Specific details of the treatments delivered are described. [ISRCTN no: 89936343].

Comparative clinical- and cost-effectiveness of candesartan and losartan in the management of hypertension and heart failure: a systematic review, meta- and cost-utility analysis

The UK National Health Service (NHS) currently spends in excess of £250 million per annum on angiotensin II receptor blockers (ARBs) for the treatment of hypertension and heart failure; with candesartan currently dominating the market. With the recent introduction of generic losartan, we set out to directly compare the branded market leader to its now cheaper alternative. The primary objectives were to compare the blood pressure (BP) lowering efficacy and cardiovascular outcomes of candesartan and losartan in the treatment of essential hypertension and chronic heart failure, respectively. The secondary objective was to model their comparative incremental cost-effectiveness in a UK NHS setting. The Cochrane Central Register of Controlled Trials (Cochrane Library 2009, issue 2), which contains the Hypertension and Heart Group's specialist register, Medline (1950-February 2010), and Embase (1980-February 2010) were included in the search strategy. Selection criteria were randomised studies of candesartan versus losartan in adults (> 18 years). The main outcome measures were as follows: Hypertension: mean change from baseline in trough (24 h postdose) systolic and diastolic BP. Heart failure: composite of cardiovascular death and hospital admission for management of heart failure. Two reviewers applied inclusion criteria, assessed trial quality, and extracted data. Eight (three of which met inclusion criteria) and zero trials compared candesartan directly with losartan in the treatment of hypertension and heart failure, respectively. A between-treatment difference of -1.96 mmHg [95% confidence interval (CI) -2.40 to -1.51] for trough diastolic BP and -3.00 mmHg (95% CI -3.79 to -2.22) for trough systolic BP in favour of candesartan was observed. Based on this differential, a 10-year Markov model estimates the cost per quality-adjusted life-year gained to exceed £40,000 for using candesartan in place of generic losartan. Candesartan reduces BP to a slightly greater extent when compared with losartan, however, such difference is unlikely to be cost-effective based on current acquisition costs, perceived NHS affordability thresholds and use of combination regimens. We could find no robust evidence supporting the superiority of candesartan over losartan in the treatment of heart failure. We therefore recommend using generic losartan as the ARB of choice which could save the UK NHS approximately £200 million per annum in drug costs.

E-mail contact as an effective strategy in the maintenance of weight loss in adults

Professional face-to-face contact is known to be beneficial in effective weight management, but costly, in supporting weight maintenance. Within the UK, studies have examined using the Internet to achieve weight loss; however, there is a need to evaluate the use of dietetic intervention via e-mail to support the maintenance of weight loss in a National Health Service (NHS) setting. The present study aimed to assess the effects of dietetic support through e-mail on weight loss maintenance on individuals who were successful in weight loss. Fifty-five patients, who had lost ≥5% body weight, were assigned to either an intervention group (weekly e-mail messages and monthly personal e-mail message with reporting of weight, n = 28) or a control group (n = 27). The level of weight maintenance, plus dietary changes and the ability to maintain a level of activity, were recorded after 6 months. At 6 months, the e-mail group maintained an average weight loss of 10%, which was significantly (P = 0.05) greater than the mean percentage weight loss maintained by the control group (7.3%). The control group regained weight at a statistically significant greater velocity (P = 0.02) than the intervention group. There were correlations between the amount of fruits and vegetables (P = 0.07) eaten and exercise episodes (P = 0.01) against weight change in maintenance. The present study showed that dietetic support using e-mail can be used effectively in reducing weight gain velocity and assisting in the maintenance of weight loss. It is a system that can be used in the UK NHS to reach many people.

Confirming the drugs administered during anaesthesia: a feasibility study in the pilot National Health Service sites, UK

BackgroundTo help prevent drug errors, it is recommended that drugs should be confirmed/checked with a second person before administration. We aimed to assess the feasibility of introducing second-person or electronic bar-code confirmation of drugs, administered during anaesthesia, in the National Health Service (NHS) settings in the UK. MethodsSeven NHS sites took part in a pilot study over a 3 month period. Five used a second-person and two used bar-code electronic confirmation of drugs given during anaesthesia. A total of 36 consultant anaesthetists and three trainees, 15 operating department practitioners (ODPs), and seven anaesthetic nurses participated. A group of anaesthetists, ODPs, and nurse practitioners (n=11) from different NHS sites independently observed both methodologies. In addition, each site was visited and observed by one of the study investigators. At the end of the study period, four focus groups (two with participants from pilot sites and two with observers) were held. The discussions were taped, transcribed, and qualitatively analysed. Data were triangulated using observer’s notes and investigator’s reflective diaries, and processed using line-by-line coding. The codes were then synthesized into themes. ResultsBoth methods were perceived to contribute to the prevention of drug errors. For the two-person confirmation to be carried out correctly, there should be no distraction or time pressure. The main limitation to the feasibility was that the continuous presence of the second person was not always possible. The process also met with resistance from the staff at some pilot sites. Electronic confirmation was always feasible, as it did not require the presence of a second person. It was found to be intuitive to the anaesthetist’s current working practice. However, there were some practical issues related to introduction of new technology and an initial learning curve. ConclusionsThe introduction of two-person confirmation to the NHS would have a significant impact on the existing working practices. Issues related to resources and a cultural change will need to be addressed. Electronic confirmation was more feasible, but the technological aspects of its integration into the operating theatre environment, and learning, will require further attention.

Health Service Inpatient Units for People with Intellectual Disabilities and Challenging Behaviour or Mental Health Problems

Background As institutions for people with intellectual disabilities have been replaced with community services, health care provision has developed to provide assessment and treatment, low and medium secure units for people with challenging behaviour or mental health problems. These include both public and private sector provision. Little is known about these services. The aim of this study was to describe the characteristics of the services studied and to compare the different types of service.Methods A survey was carried out of National Health Service (NHS) and independent sector (IH) health settings providing specialist inpatient services for people with intellectual disabilities. Data were collected on setting and patient characteristics, staffing and management and care processes and outcomes.Results Services were very unevenly distributed across England. There were differences between NHS and IH settings. IH assessment and treatment units were bigger, had higher occupancy and lower staff ratio. In all three types of unit, IH units had fewer visits to patients, used more seclusion, physical restraint and had more locked areas. They had more complaints in more services from users and (for assessment and treatment units and low secure units only) from relatives. In low secure units, they had more adult protection referrals. On the other hand, IH units used fewer agency staff in assessment and treatment units (though more in medium secure units) and provided more appraisals, more visits from commissioners, more consultations with GPs and dentists and more use of whistleblowing procedures by staff. A quarter of people in NHS assessment and treatment units had finished treatment but had no plan for discharge.Conclusions Further research is required to determine the reasons for differences observed between IH and NHS units. The large number of people who have finished treatment emphasizes the importance of developing housing in the community with sufficiently skilled support. The large number of patients in low secure services raises the question whether this type of service is recreating the intellectual disability institutions which government policy intends to close.

The availability and use of allied health care in care homes in the Midlands, UK

Aims A review by an international charity for older people, Help the Aged, suggested that older people living in care homes in the UK do not receive the appropriate levels of access to health professionals. The authors aimed to establish the access to and use of services provided by allied health professions to care homes in Oxfordshire and Warwickshire. Methods A postal survey with telephone follow up of the use of and access to allied health-care services in 121 Oxfordshire and Warwickshire care homes was conducted using an established questionnaire. Findings The majority of homes reported using a chiropodist (91%), an optician (86%), hearing services (63%) and a physiotherapist (65%). Less than half of the homes reported using an occupational therapist (41%), a dietician (44%) or a speech and language therapist (39%). A third used an alternative therapist (35%) and a similar number (35%) a social activities organizer. There was inconsistency in the sources of funding and the reasons for referral, particularly regarding occupational therapy and the provision of aids and adaptations. Conclusions The expertise of allied health-care professions available in UK hospital and domiciliary National Health Service (NHS) settings is not evident or accessible in the care home setting unless funded privately. When taking into account the high levels of impairments in these settings, access would appear to be contrary to the UK National Service Framework for Older People, which suggests that the NHS will provide a universal service for all based on clinical need, not ability to pay.

On the Ethics Committee: The Expert Member, the Lay Member and the Absentee Ethicist

This paper considers the roles and definitions of expert and lay members of ethics committees, focussing on those given by the National Research Ethics Service which is mandated to review all research conducted in National Health Service settings in the United Kingdom. It questions the absence of a specified position for the ‘professional ethicist’ and suggests that such individuals will often be lay members of ethics committees, their participation being a reflection of their academic interest and expertise. The absence of a specified position for professional ethicists and the concomitant but implicit denial of ethical expertise appear to be an anomalous state of affairs if one considers that the training offered to members of ethics committees is often delivered by academic ethicists. It is suggested that this is based on a misunderstanding of the concept ‘ethical expertise’ and that properly understood the ethicist can assist the work of ethics committees by drawing on their expert knowledge.

Development and delivery of a physiotherapy intervention for the early management of whiplash injuries: The Managing Injuries of Neck Trial (MINT) Intervention

This paper describes the development and implementation of a physiotherapy intervention for a large multicentred randomised controlled trial of the early management of whiplash injuries in a National Health Service setting. Participants were eligible if they were classified as having whiplash-associated disorder grades I to III and self-referred for treatment within 6 weeks of injury. The intervention development was informed through a variety of methods including the current evidence base, published guidelines, clinician opinion, a pilot study and expert opinion. The intervention was targeted at known, potentially modifiable risk factors for poor recovery, and utilised manual therapy, exercises and psychological strategies. The treatment was individually tailored, with a maximum of six treatments allowed within the trial protocol over an 8-week period. The intervention was delivered to 300 participants. The amount and types of treatments delivered are described.

To admit or not: the use of camera mobile phone in trauma and orthopaedics at night

Introduction Mobile phones with incorporated digital cameras have become increasingly sophisticated. Their use in transmitting images for clinical decision making has been described in Otolaryngology, Neurosurgery, and Plastic Surgery, but not in the field of trauma and orthopaedics in the National Health Service (NHS) setting.

A retrospective audit of patients with osteo-arthritic knees treated with prolotherapy in a general practice

Objective: The objective of this study was to assess the effects of dextrose prolotherapy on knee osteoarthritis. Patients and methods: A retrospective audit of treated series using a postal questionnaire and general practitioner (GP) records was conducted in UK National Health Service (NHS) general practice. Participants included 48 men and women with self-reported knee pain, treated by prolotherapy 3–43 months previously. Outcome measures were retrospective numerical visual analogue scale (VAS) scores pre- and post-treatment and self-reported duration of pain relief, reduction in analgesia requirement, severity of osteoarthritis on X-ray and any subsequent knee replacement referral. Results: There were 42 (85%) respondents to the postal questionnaire. Median follow-up was 30 months. Of respondents, 83% reported benefit, 75% for more than 3 months, and 26% for more than 1 year. Mean reduction of VAS score for the population was 3.5 (P < 0.001), suggestive of a significant clinical effect. There was no statistical difference in response of any subgroup examined. Conclusions: These results suggest a genuine effect, but the study is obviously inconclusive. However, it provides a good case for conducting a formal randomised controlled trial against usual care in knee osteoarthritis in an NHS setting.

A Multicenter Trial of an Assess-and-Fit Hearing Aid Service Using Open Canal Fittings and Comply Ear Tips

Large potential benefits have been suggested for an assess-and-fit approach to hearing health care, particularly using open canal fittings. However, the clinical effectiveness has not previously been evaluated, nor has the efficiency of this approach in a National Health Service setting. These two outcomes were measured in a variety of clinical settings in the United Kingdom. Twelve services in England and Wales participated, and 540 people with hearing problems, not previously referred for assessment, were included. Of these, 68% (n = 369) were suitable and had hearing aids fitted to NAL NL1 during the assess-and-fit visit using either open ear tips, or Comply ear tips. The Glasgow Hearing Aid Benefit Profile was used to compare patients fitted with open ear tips with a group of patients from the English Modernization of Hearing Aid Services evaluation, who used custom earmolds. This showed a significant improvement in outcome for those with open ear tips after allowing for age and hearing loss in the analysis. In particular, the benefits of using bilateral open ear tips were significantly larger than bilateral custom earmolds. This assess-and-fit model showed a mean service efficiency gain of about 5% to 10%. The actual gain will depend on current practice, in particular on the separate appointments used, the numbers of patients failing to attend appointments, and the numbers not accepting a hearing aid solution for their problem. There are potentially further efficiency and quality gains to be made if patients are appropriately triaged before referral.

A Comparison Between Chiropractic Management and Pain Clinic Management for Chronic Low-Back Pain in a National Health Service Outpatient Clinic

To compare outcomes in perception of pain and disability for a group of patients suffering with chronic low-back pain (CLBP) when managed in a hospital by either a regional pain clinic or a chiropractor. The study was a pragmatic, randomized, controlled trial. The trial was performed at a National Health Service (NHS) hospital outpatient clinic (pain clinic) in the United Kingdom. Patients with CLBP (i.e., symptom duration of >12 weeks) referred to a regional pain clinic (outpatient hospital clinic) were assessed and randomized to either chiropractic or pain-clinic management for a period of 8 weeks. The study was pragmatic, allowing for normal treatment protocols to be used. Treatment was administered in an NHS hospital setting. The Roland-Morris Disability Questionnaire (RMDQ) and Numerical Rating Scale were used to assess changes in perceived disability and pain. Mean values at weeks 0, 2, 4, 6, and 8 were calculated. The mean differences between week 0 and week 8 were compared across the two treatment groups using Student's t-tests. Ninety-five percent (95%) confidence intervals (CIs) for the differences between groups were calculated. Randomization placed 12 patients in the pain clinic and 18 in the chiropractic group, of which 11 and 16, respectively, completed the trial. At 8 weeks, the mean improvement in RMDQ was 5.5 points greater for the chiropractic group (decrease in disability by 5.9) than for the pain-clinic group (0.36) (95% CI 2.0 points to 9.0 points; p = 0.004). Reduction in mean pain intensity at week 8 was 1.8 points greater for the chiropractic group than for the pain-clinic group (p = 0.023). This study suggests that chiropractic management administered in an NHS setting may be effective for reducing levels of disability and perceived pain during the period of treatment for a subpopulation of patients with CLBP.

Economic aspects of a therapy and support service for people with long‐term stroke and aphasia

This paper considers some economic aspects of a therapy and support service for people with stroke and aphasia. This material was part of a broader evaluation of the service, which is reported elsewhere (van der Gaag et al. 2005, van der Gaag and Mowles 2005). The purpose of this part of the study was to investigate the feasibility of undertaking economic appraisal in a voluntary sector service providing therapy for people with aphasia and their families. The costs of delivering therapy and support services were calculated. These costs were compared with the costs of equivalent services in the National Health Service (NHS). The EQ-5D health-related quality of life instrument was used to calculate quality-adjusted life years (QALYs). The cost of delivering therapy was lower than expected for a customized service of this nature. The study generated cost data for delivering therapy services, allowing some comparisons to be made with equivalent services in NHS settings. QALY data were generated for a sample of 25 clients on one of the programmes. The economics of speech and language therapy service delivery have received scant attention in the published literature. The paper argues that decision-making about methods of service delivery can be aided by the explicit consideration of the costs and consequences of different programmes.