Secondary Care Resources Research Articles

Managing inflammatory bowel disease care closer to home: anti-tumour necrosis factor (TNF) therapy

The incidence of inflammatory bowel disease (IBD) continues to increase, and the approaches to management are becoming more complex and demanding. The use of anti-tumour necrosis factor (TNF) therapy to manage IBD is also growing. This has increased the demand on secondary care resources to accommodate patients, in terms of frequent admissions. Therefore, the administration of anti-TNF treatment in the community should be adopted. The following article analyses the political agenda, in particular the Care Closer to Home initiative and the long-term conditions agenda, and how the expansion of primary-care-based anti-TNF services will enable patient-centred care to be developed and political agendas to be met.

British Thoracic Society Paediatric Pneumonia Audit: a review of 3 years of data

The British Thoracic Society (BTS) guidelines for the management of community-acquired pneumonia in children are used as the audit standard for the annual BTS Paediatric Pneumonia Audit. This report examines...

Defining primary care sensitive conditions: a necessity for effective primary care delivery?

Primary care is a major component of England's National Health Service (NHS), responsible for approximately 300 million consultations per year with GPs in England, which represents 70-90% of all patient contacts with the NHS. In addition to providing healthcare to the registered population, GPs are charged with coordination and gatekeeping of access to services provided by secondary care, tertiary care and other allied healthcare providers. As GPs will be assuming a key role in commissioning health services in England, there is a clear opportunity to re-model care delivery to maximize outcomes, cost efficiency and patient access by focusing on diseases that are most amenable to management in primary care. It is essential that there is evidence to inform what conditions are most sensitive to management in primary care - commonly referred to as primary care sensitive conditions or ambulatory care sensitive conditions. Such definitions would aid resource planning, drafting of local management protocols and simplification of the interface between primary and secondary care for a number of chronic conditions. Indeed, inappropriate utilization of secondary care resources is likely to represent a significant opportunity cost to healthcare providers and may be less desirable for patients.

Resource Utilization and Outcomes in Patients with Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained disorder of cardiac rhythm. Various new anticoagulation and antiarrythmic treatments are being investigated for the treatment of AF. Before novel treatments can be used widely in actual clinical practice, the cost effectiveness of such novel treatments may need to be determined. The objectives of the study were to describe resource utilization for AF and control patients, and estimate the incidence of mortality. This case control study evaluated 6 months of primary and secondary care resource utilization and mortality rates for patients within the period 01 April 2001 to 31 March 2006. Cases included 15 373 adults with a record of AF in the General Practice Research Database (GPRD) within the study period. The index date was randomly selected between 6 months after the AF record and end of data collection. Cases were matched to controls by age, gender, general practice and time. AF patients had significantly higher resource utilization than controls. Resource utilization increased with greater National Institute for Clinical Excellence (NICE) stroke risk strata (graded as low, moderate or high based on associated risk factors). Both current warfarin and aspirin users had higher resource utilization than control patients. Resource utilization remained high amongst AF patients who discontinued therapy. The mortality rate was significantly higher in AF patients than controls, deaths due to circulatory system disease were increased 4-fold and cancer deaths were doubled. All-cause and circulatory mortality rates, as well as rates of clinical outcomes, were related to the NICE stroke risk schema. There was large heterogeneity in resource utilization between AF patients, although overall, this was still higher than controls without AF. Higher resource utilization was evident in patients at higher risk of stroke, and remained where antithrombotic therapy was discontinued. The mortality risk in AF was increased substantially, both for cardiovascular and non-cardiovascular causes of death, indicating a large unmet medical need.

Views of health professionals on the role of primary care in the follow-up of men with prostate cancer

Follow-up care for prostate cancer has traditionally been led by secondary care in hospital out-patient clinics. As the number of men with prostate cancer increases and secondary care resources face pressure, alternative follow-up models are being sought. Current National Institute for Health and Clinical Excellence guidance recommends follow-up outside the hospital setting for patients who are stable 2 years following radical treatment and for those undergoing 'watchful waiting'. To describe current practice in a sample of relevant health care professionals and to seek their views on the role of primary care in prostate cancer follow-up. Semi-structured telephone interviews with 38 UK health care professionals, from both secondary and primary care. Transcripts were analysed using the constant comparative method. There are marked variations in current follow-up practice around the country, with hospital-based follow-up ranging from 6 months to lifetime. The predominant, although not universal, view expressed was that there is both scope and support for primary care to play a greater role, particularly for men with stable disease. This was qualified by the need for supporting education, including guidance on interpretation of prostate-specific antigen values, introduction of robust follow-up systems in primary care, easy access back into secondary (hospital) care, a mechanism for ensuring follow-up data can still be collected for audit purposes and appropriate resourcing. If primary care is to play a significant role in providing high-quality follow-up care for men with prostate cancer, then steps need to be taken to address the barriers to increased primary care involvement identified by this study.

An evaluation of the impact of biologic therapy on secondary care resource use associated with the management of crohn's disease in the UK

IntroductionPrevious studies with anti-TNF drugs1–3 for Crohn's disease (CD) showed a reduction in cost by reducing hospitalisations, examinations under anaesthetic (EUA) and diagnostic procedures. However no study has looked at...

Emergency ultrasound in the prehospital setting

Paramedic practice in the UK has seen some diverse and lengthy changes in the last ten years. The way that ambulance services are now involved in emergency care is very different, with more focus placed on the efficient and appropriate use of other primary and secondary care resources. The advent of closer and more formal working relationships between prehospital care physicians and paramedics will provide the opportunity to further develop the quality of care delivered by the doctor-paramedic team. It is now widely accepted that for the most seriously injured patients out of hospital, the application of physician-led skills such as prehospital anaesthesia contribute significantly to the process of the early management of trauma and improvement of outcome ( Van der Hoeven and De Koning, 1995 ). Similarly, the development of the team approach has meant that more goal–led therapies can be instituted in a timely fashion. The use of ultrasound in the prehospital environment is not new. While its role is not yet fully established ( Brooke et al. 2010 ), it is nevertheless finding its rightful place in the hands of both trained physicians and paramedics. The diversity of applications for paramedic–led ultrasound is also gaining momentum with high levels of sensitivity and specificity reported ( Heiner and McArthur, 2010 ; Tazarourte et al, 2010 ). This article addresses some of the issues regarding the use of ultrasound in prehospital care and describes some of the applications which are taught in the emergency and prehospital ultrasound course at the Imperial College, London.

A psoriasis-specific model to support decision making in practice – UK experience

Objectives:The balance of service provision for people with psoriasis across community and hospital sectors is inappropriate in many localities. Disease-specific models are being used by policy makers to inform public health decision making and guide their long-term budgets. The aim of the present study was to develop an interactive psoriasis model to compare the 2-year outcomes of topical treatment strategies in patients with moderately severe psoriasis in real-world settings.Research design and methods:A previously published 1-year economic analysis of the two-compound formulation (TCF) calcipotriol plus betamethasone dipropionate and other commonly used topical agents in plaque psoriasis was adapted. Literature review and an interview programme identified additional relevant data to inform model assumptions. The model estimated local psoriasis costs and resources in accord with decision makers’ priorities. A key element of the model was the facility for all default input data to be adapted to reflect local circumstance. Model validation was not undertaken. The UK experience is described.Results:Topical treatment with high-efficacy first-line therapies is a cost-effective treatment strategy in moderate plaque psoriasis. The model predicts potential savings in psoriasis care for a UK population of £126 million over 2 years if all psoriasis patients received the TCF in a community setting. A frequently used feature of the model was to identify ways of reducing inappropriate referrals to hospital, and so enabling secondary care resources to be focussed on the most resilient psoriasis cases.Conclusions:The present study psoriasis disease model could facilitate collaboration between healthcare professionals to optimise healthcare in the UK. Psoriasis management strategies in primary care can be compared in a variety of realistic clinical settings, allowing the identification of optimal treatment regimens. This model is adaptable to tailor inputs to reflect local situations, providing an attractive tool to GP commissioners. Country-specific adaptations are being researched in other European countries.

Asthma Programme in Finland: Did the use of secondary care resources become more rational?

The aims were to evaluate the profile of newly diagnosed adult asthma cases and the approach adopted to the secondary care management at the launch of the Finnish asthma programme in 1994 and seven years later, in 2001. A retrospective medical record audit was made of non-acutely referred patients with asthma in 1994 (n=165) and in 2001 (n=133). Clinical profile data, numbers of out-patient visits and periods of in-patient care before and after asthma diagnosis were gathered from referral letters and secondary care records. The newly diagnosed asthma patients in 2001 were older, more obese and had more co-morbidities. The main asthma symptoms, such as dyspnoea, wheezing and cough, occurred equally in both years but were more often periodic than daily in 2001. Wheezing during auscultation was significantly less common in 2001. The diagnostic process was associated to a history of asthma in first-degree relatives (OR 5.34, 95% CI 1.12-24.49) in 1994 and a visit to a nurse prior to that to a physician (OR 3.13, 95% CI 1.17-8.37) in 2001. Secondary care visits per new case of asthma (7.3 in 1994 vs. 5.4 in 2001) and days in hospital (3.6 in 1994 vs. 0.95 in 2001) decreased significantly. The profile of asthma diagnosed in secondary care indicates milder disease with more co-morbidities in 2001 than in 1994.Trends towards assigning a more active role on the part of primary care physicians and more rational use of secondary care resources in the management of asthma were found.

PMS63 COMPARISON OF STAFF RESOURCES AND PATIENT TIME REQUIRED FOR RITUXIMAB AND INFLIXIMAB ADMINISTRATION IN 3 UK NHS HOSPITALS

Background  Rituximab and infliximab are biologic disease modifying anti-rheumatic drugs (DMARDs) used to treat rheumatoid arthritis (RA).  Rituximab is commonly re-dosed when signs and symptoms return, but infliximab has fixed dosing intervals.  Results from a recent single centre study suggest that the different administration requirements do have an impact on resource use1.  The secondary care resource and patient time implications of this difference were determined in this 3-centre observational study. Table 4: Mean total NHS staff time in 43 week assessment period

The effect of concurrent pain on the management of patients with depression: an analysis of NHS healthcare resource utilisation using the GPRD database

Patients with depression frequently report painful physical symptoms. However, there are scant data from the UK concerning differences in primary and secondary care resource use between depressed patients with and without pain treated in general practice. Patients with depression codes were identified from the General Practice Research Database (GPRD) excluding those with psychoses. The observation period was 1st January 2000-31st December 2006. Patients were further categorised into three groups: (i) no painful physical symptom codes ever in the observation period (NO PAIN); (ii) patients with no other diagnostic or test codes 30 days either side of a pain code (PAIN MINUS DIAGNOSIS) and (iii) patients with pain codes and other diagnostic codes (PAIN PLUS DIAGNOSIS). Rates of general practitioner (GP) visits, antidepressant and concomitant prescribing and switching, secondary care referrals and diagnostic tests were reported per group with 95% confidence limits (CI). A total of 145,784 patients with depression aged 18-50 years were selected. Of these, 48,615 (33.3%) were classed as NO PAIN, the remaining 66.6% having pain. PAIN MINUS DIAGNOSIS patients constituted 5654 (5.8%) of those with pain. PAIN MINUS DIAGNOSIS and PAIN PLUS DIAGNOSIS had a significantly higher rate of GP visits than NO PAIN patients, 10.37 (95% CI 10.23, 10.52); 11.15 (11.11,11.20) and 7.04 (7.00, 7.08) respectively. Inter and intraclass drug switching was high with 13% of PAIN MINUS DIAGNOSIS and 14% of PAIN PLUS DIAGNOSIS patients having three or more switches compared with 7% of NO PAIN patients. Referral rates to secondary care were significantly higher in both pain groups compared with patients with no pain. Diagnostic testing was significantly greater in PAIN MINUS DIAGNOSIS and PAIN PLUS DIAGNOSIS groups than NO PAIN patients for all test types, with X-rays being the most common test; 3.85 (3.69,4.00); 2.77 (2.74,2.80); 0.91 (0.89, 0.94) respectively. Patients in general practice diagnosed with depression and concurrent painful physical symptoms have higher resource use in primary and secondary care.

Impact of risperidone long acting injection on resource utilization in psychiatric secondary care

Risperidone long acting injection (RLAI) is the only long acting atypical antipsychotic available in the UK. Its impact on NHS resource use has not been widely studied. This review of medical records was conducted to quantify the impact of RLAI on NHS psychiatric secondary care resource use, primarily in terms of episodes of inpatient hospital care 12 months before and 12 months after RLAI initiation. Data on number of hospitalizations and hospital bed days were collected retrospectively, from patient notes and hospital databases in four acute psychiatric units in the UK for all individuals with a diagnosis of schizophrenia or schizoaffective disorder who were prescribed RLAI more than 12 months previously. Data were collected on 100 individuals (58 male) with a mean age 40.8 years (range 19-70). The median duration of illness before RLAI initiation was 12 years (range six months to 43 years). There were 62 admissions in the 12 months pre-RLAI, falling to 22 admissions in the 12 months post-RLAI. Number of admissions, we argue, offer a more reliable indicator of the impact of treatment than total hospital bed days in this type of study. In this study there were 40 fewer admissions in the 12 months after RLAI was initiated compared with the previous 12 months. This is important as readmission is a good proxy measure of relapse, and adherence to medication is known to be a key factor in relapse prevention.

P78. NHS resource use and capacity planning in breast cancer patients with metastatic bone disease treated with IV zoledronic acid or oral ibandronic acid

Objectives: To describe the management pathways of metastatic bone disease with IV zoledronic acid (ZA) and oral ibandronic acid (IA) and to quantify the impact on secondary care resources for capacity planning.

What's It Like in My Patch?

Recently I learnt of a meeting arranged between my Acute Trust and the local Primary Care Trust. It was to explore transfer of diabetes care from secondary to primary sectors. Neither I nor my two diabetologist colleagues (serving a population of around 600 000 between us) were invited. However, we are now included and at a recent first meeting set out to establish some common ground. We easily agreed the principle that care should be carried out by the most appropriate person nearest to the patient. We also agreed the ‘motherhood and apple pie’ principles that care should be seamless and transition between community and hospital simple in either direction. We envisage three groups of patients — those who require hospital care, those best managed in the community, and an ‘intermediate’ group where there is a lack of consensus! The devil, of course, will be in the detail… My colleagues and I have produced a short list (for debate) of those patients we consider best seen in hospital. This encompasses only about 50% of those currently attending. My early steps to discharge these or, at the least, to transfer their routine annual review examination to their GP or practice nurse have been met with cries of ‘dumping’ (the Local Negotiating Committee) or ‘at last’ (keen GPs). In reality, the Quality and Outcomes Framework has meant a de-facto transfer of money for diabetes care to primary care. One or two further diabetologist appointments were promised but are now unlikely to materialise due to financial difficulties (exacerbated by our Private Finance Initiative development). My clinic has the support of less than two dietetic and one podiatry sessions weekly. Podiatry is community resourced and controlled. There is no dedicated Clinical Psychology support. Retinal screening is provided by a private medical imaging firm with mobile camera sessions. Diabetes specialist nurses (DSNs) are being asked to work a weekly general nursing session on the wards to save use of bank staff. In the longer term there is talk of all DSNs being transferred to the community — they have always had an important role in skilling practice teams but they do not expect to remain up-to-date divorced from a consultant clinic. Our hospital information systems do not yet support useful diabetes clinical data sets. Our Area Prescribing Committee is short of cash and loath to approve use of many existing and newer agents. To be fair, our senior executives are aware of the needs of diabetic patients and the extra costs of managing them sub-optimally. However, their financial timescale is rather shorter than our clinical one. We feel that we are a reasonably flexible bunch of diabetologists without any particular yearning for ‘empire’. But, if secondary care resources are lost, or fail to expand with demand, then there will be insufficient staff left to deal with difficult problems. As patient numbers increase we will shortly have to move to a ‘see and return’ system of care without responsibility for long-term management. The suggestion from some quarters in primary care that we become peripatetic ‘white van men’ fills me with horror. Hopefully we can win the argument locally that a critical mass of specialist resources is required to prevent hospital beds in the future filling with patients with severe but preventable complications. If we cannot, then specialist teams to manage them will disappear as potential trainees make alternative career choices. Perhaps our diabetes service will go the same way as the old TB doctors — but at least they were rescued by an epidemic of asthma!

Collaboration with general practitioners: preferences of medical specialists – a qualitative study

BackgroundCollaboration between general practitioners (GPs) and specialists has been the focus of many collaborative care projects during the past decade. Unfortunately, quite a number of these projects failed. This raises the question of what motivates medical specialists to initiate and continue participating with GPs in new collaborative care models.The following question is addressed in this study: What motivates medical specialists to initiate and sustain new models for collaborating with GPs?MethodsWe conducted semi-structured interviews with eighteen medical specialists in the province of Groningen, in the North of The Netherlands. The sampling criteria were age, gender, type of hospital in which they were practicing, and specialty. The interviews were recorded, fully transcribed, and analysed by three researchers working independently. The resulting motivational factors were grouped into categories.Results'Teaching GPs' and 'regulating patient flow' (referrals) appeared to dominate when the motivational factors were considered. In addition, specialists want to develop relationships with the GPs on a more personal level. Most specialists believe that there is not much they can learn from GPs. 'Lack of time', 'no financial compensation', and 'no support from colleagues' were considered to be the main concerns to establishing collaborative care practices. Additionally, projects were often experienced as too complex and time consuming whereas guidelines were experienced as too restrictive.ConclusionSpecialists are particularly interested in collaborating because the GP is the gatekeeper for access to secondary health care resources. Specialists feel that they are able to teach the GPs something, but they do not feel that they have anything to learn from the GPs. With respect to professional expertise, therefore, specialists do not consider GPs as equals. Once personal relationships with the GPs have been established, an informal network with incidental professional contact seems to be sufficient to satisfy the collaborative needs of the specialist.The concerns seem to outweigh any positive motivational forces to developing new models of collaborative practice.

Cost and health status analysis after autologous chondrocyte implantation and mosaicplasty: A retrospective comparison

Chondral defects of the knee cartilage are prevalent. Autologous chondrocyte implantation (ACI) and mosaicplasty are increasingly used to treat symptomatic knee defects. This study assessed the costs and health status outcomes after ACI and mosaicplasty. Patients were eligible to participate in this cross-sectional study if they received ACI or mosaicplasty at the Royal National Orthopaedic Hospital between 1997 and 2001 or were on a waiting list for ACI. Secondary-care resource use was collected to 2 years postoperatively using a resource collection proforma. Participants responded to postal questions about sociodemographic characteristics and knee-related (Modified Cincinnati Knee Rating System) and general health status (EQ-5D). Fifty-three ACI, twenty mosaicplasty, and twenty-two patients waiting for ACI participated. The average cost per patient was higher for ACI (10,600 pounds sterling: 95 percent confidence interval [CI], 10,036 pounds sterling-11,214 pounds sterling) than mosaicplasty (7,948 pounds sterling: 95 percent CI, 6,957 pounds sterling-9,243 pounds sterling). Postoperatively, ACI and mosaicplasty patients (combined) experienced better health status than those waiting for ACI. ACI patients tended to have better health status outcomes than mosaicplasty patients (not statistically significant). Estimated average EQ-5D social tariff improvements for quality-adjusted life year (QALY) calculations were 0.23 (ACI) and 0.06 (mosaicplasty). Average costs per QALY were 23,043 pounds sterling (ACI) and 66,233 pounds sterling (mosaicplasty). The incremental cost effectiveness ratio (ICER) for providing ACI over mosaicplasty was 16,349 pounds sterling. Average costs were higher for ACI than mosaicplasty. However, both the estimated cost per QALY and ICER for providing ACI over mosaicplasty fell beneath an implicit English funding threshold of 30,000 pounds sterling per QALY. Prospective studies should include measures of utility to confirm the estimated cost utility ratios of ACI and mosaicplasty.

Questioning workload resources

Available technology assists managers with fiscally sound predictions of staffing and secondary patient care resources.

P0670 COST OF PAEDIATRIC INFLAMMATORY BOWEL DISEASE: ONE YEAR PREVALENCE COHORT STUDY

Introduction: Ulcerative Colitis (UC) and Crohn’s disease (CD) are chronic disorders that may require repeated medical interventions. Detailed data describing levels of resource use and cost of illness for IBD in paediatric population are lacking for the UK. The aims of this study is to describe demographics and produce a detailed profile of secondary care resource use and cost for IBD patients managed at a single centre. Methods: Children receiving any form of care for IBD at a tertiary referral centre over a year were identified. Case note review of all confirmed cases was done and resource use during the study time frame was abstracted. Item costs were taken from local and / or national sources. Results: Data relating to 150 IBD patients were analysed (UC: n=59, CD: n=82, Indeterminate Colitis: n = 9) Mean age [SD] and mean duration of disease were: UC 12.6(3.7) yrs and 2.4 yrs; CD 13.7(2.8) yrs and 2.4 yrs. Mean age at diagnosis (UC; CD): 10; 11 yrs. Seven CD patients (8.5%) had perianal disease / fistulating complications. 11 patients (7%) had evidence of extra-intestinal manifestations [sclerosing cholangitis(1), arthritis(1), sacroilitis(1), uveitis(2) and erythema nodusum(5)]. For UC versus CD: Acute flare needing immunosuppressants / elemental diet 47% v 40%; hospitalisation rate 19% v 44%; surgery 6% v 7%. Resource Use- Mean use/patient/year for UC versus CD, respectively: Outpatient Consultations (IBD related): 2.4v2.8; Outpatient Consultations (for extraintestinal manifestations of IBD): 0.09v0.14; Blood tests: 2.4v2.8; Radiology: 0.15v0.17; Day case endoscopies: 0.6v0.5. Inpatient episodes: 0.24v0.5; Length of each inpatient stay (days): 5.5v6.5. Surgical episode: 0.06v0.07. Cost data – see table 1.Table 1: Direct Medical Costs: Total (mean) £s/patient/yearConclusion: In patient care accounts for 63% and 71% of overall direct costs respectively for UC and CD, though is required for a minority of subjects. The information on resource use will help in service planning for patients with IBD.

Quality of GPs' referral letters to diabetes secondary care

AbstractGood quality referral information enables appropriate triage and the best use of scarce secondary care resources. We evaluated the quality of GPs' referral letters to our district general hospital diabetes centre to identify types of information that receive the highest and the least priority with the objective of developing constructive feedback.Eighty‐one letters from 51 GPs, excluding requests for reassessment, emergency inpatient care or non‐diabetic concerns, were evaluated on 24 parameters of varying clinical importance and categorised as ‘low’(0.0–9.9), ‘mid’(10.0–19.9) or ‘high’ (20.0–30.0) scoring (total 30.0 points).Total scores ranged from 4.5 to 30 (mean 13.3). Mean per cent scores (95% confidence intervals), for selected parameters were: home glucose monitoring 29.6 (19.9 to 39.3); HbA1c 47.8 (38.3 to 57.4); retinal surveillance 32.1 (21.9 to 42.3) and complications 30.9 (20.9 to 40.8); microalbuminuria 28.4 (18.4 to 38.3) and renal complications 23.5 (14.3 to 32.6); foot care 19.8 (11.0 to 28.5) and complications 24.1 (14.9 to 33.2); blood pressure 41.4 (30.9 to 51.8); bodyweight 30.3 (20.9 to 39.6). Low‐scoring letters (32.1%) regularly provided five items of information, mid‐scoring (51.9%) 10 items and high‐scoring (16.1%) 20 items.Overall, letters were lacking in information regarding surveillance, recognition and management of microangiopathy, blood pressure, body weight, home glucose monitoring and biochemistry. High‐scoring letters reflected good insight into the care of people with diabetes. Copyright © 2003 John Wiley & Sons, Ltd.

Open access follow up for inflammatory bowel disease: pragmatic randomised trial and cost effectiveness study

Objective: To evaluate whether follow up of patients with inflammatory bowel disease is better through open access than by routine booked appointments.Design: Pragmatic randomised controlled trial.Setting: Two district general hospitals...