Use of regression analysis to explain the variation in prescribing rates and costs between family practitioner committees.

There are proposals to set up prescribing budgets for family practitioner committees (now family health services authorities) and indicative prescribing amounts for practices. An intelligible model is therefore required for specifying budgetary allocations. Regression analyses were used to explain the variation in prescription rates and costs between the 98 family practitioner committees of England and Wales in 1987. Fifty one per cent of the variation in prescription rates and 44% of the variation in prescription costs per patient could be explained by variations in the age-sex structure of family practitioner committees. The standardized mortality ratio for all causes and patients in 1987, and the number of general practice principals per 1000 population in 1987, but not the Jarman under-privileged area score were found to improve the predictive power of the regression models significantly (P less than 0.01). The predictions of the model for the 10 family practitioner committees with the highest and lowest prescription rates or costs are reported and discussed. Potential improvements in models of prescribing behaviour may be thwarted by two problems. First, the paucity of readily available data on health care need at family practitioner committee and practice levels, and secondly, the increasing complexity in the statistical techniques required may render the procedure less intelligible, meaningful and negotiable in a contentious field.

Modifying clinical practice: two initiatives in the English National Health Service.

Two information systems in the English National Health Service (NHS) are described and discussed. The performance indicator scheme enables service inputs and activity to be readily compared between district health authorities (DHAs) or hospitals. Quality of care is not measured directly by performance indicators but in certain circumstances a limited assessment may be inferred from the health service input and activity data. Experiments in management budgeting and resource management are reported in which the NHS accounting system is being changed to one which is more patient-based and from which costs can be identified for clinically meaningful groups of patients. Variation in service activity, derived from the performance indicator system, has been used by the government with other evidence to make the case for NHS reform. Realistic implementation of the proposed NHS reforms will depend on the success of the budgeting experiments.

Monitoring regional performance in general hospital psychiatry: England, Wales and Czechoslovakia.

The purpose of this article is to consider how the regional performance of general hospital psychiatry may be adequately monitored using routine information. Limitations on the types of information available for monitoring regional performance are discussed, in the context of the main functions which a routine information service may be expected to fulfill. English and Welsh routine data are used in a study of the utilisation of general hospital psychiatric beds, and then compared with similar data for Czechoslovakia. The findings suggest that regional equity in the provision of beds: as measured by the coefficient of variation of the bed supply rate, and national performance, as measured by the 'marginal throughput' of these beds; is superior in Czechoslovakia despite recent additions to such beds in England and Wales. The model of utilisation, which was used to assess national performance, may be used to identify the regions whose performance is substandard when compared to other regions or countries. Finally, the relevance of these proposals for monitoring Health Service performance generally is discussed.

Routine information systems in psychiatry.

Studies using data from routine psychiatric information systems must be interpreted in the light of the biases that can arise from their use. Data on utilisation of services is most commonly available but subject to the influence of enabling factors. Direct measures of quality are usually missing from routine systems. The results of a study of equity, performance and the influence of resource supply in general hospital psychiatry are summarised.

Medicinal self-poisoning and prescription frequency.

Deliberate non-fatal self-poisoning due to medicinal agents more than doubled in England and Wales during the period 1968-78. Interregional analysis showed a significant positive correlation between the rate at which psychotropic drugs were prescribed by general practitioners (GPs) and the medicinal self-poisoning rate. Regression analysis indicated that a reduction of 1000 psychotropic prescriptions would be associated with 3.8 fewer self-poisoning admissions due to medicinal agents. Causal and non-causal links between the psychotropic prescription rate and the medicinal self-poisoning rate were both considered, but the balance of the evidence seems to favour the causal interpretation. Overall, it is suggested that the benefits of such reduced prescribing outweight the costs. A significant relationship was not found between unemployment and medicinal self-poisoning.

Prescription frequency, iatrogenesis and economic evaluation.

Iatrogenesis is classified into two broad types: direct and indirect. By indirect iatrogenesis is meant the accidental or deliberate misuse of prescribed medication. Deliberate indirect iatrogenesis is explored through an analysis of deliberate non-fatal self-poisoning. A statistically significant relationship, previously found, between deliberate non-fatal self-poisoning and the frequency of prescription of psychotropics is used to evaluate the economic consequences of self-poisoning to the hospital sector. In the decision to use or not to use a particular drug, the importance of risk-benefit analysis is stressed. This analysis is used to distinguish between a drug's safety and efficacy. In general, no one criterion should be used to choose between alternative drugs. Finally, some policy implications of the analysis for psychotropic prescriptions are considered.

Physicians and medical innovation.

Previous attempts to model some aspects of physician behaviour include those of Evans, Sloan and Feldman and Wolfson. It is suggested that the introduction of knowledge as a distinct element in a microeconomic model of physician behaviour is preferable to the inclusion of a variable called 'discretionary influence' or 'quality of care' in the physician's utility function. This is because the properties of functions containing either of these variables appear to be indeterminate. By comparison the properties of the knowledge constraints can be specified with some confidence. The factors affecting a physician's demand for treatment on behalf of patients are identified as (1) the physician's objective function, (2) his knowledge and (3) the availability of medical resources. Furthermore, the knowledge element can be sub-divided into two parts: the set of prior probabilities and the set of likelihood functions. The former may be identified with the physician's local knowledge, whereas the latter may be associated with the physician's medical training. A significant fraction of the growing demand for hospital care has been attributed to changes in medical technology. During the late fifties and afterwards 'more cases became treatable' and physicians, it is argued, cannot resist the 'technological imperative'. The paper shows that the model may be used to generate testable hypothesis regarding the adoption by physicians of both process and product innovations. The discussion of the physician's medical knowledge is fundamental to the inducement mechanism. The policy instruments available to achieve an optimal diffusion of innovations are reviewed.

Cost-effectiveness study of outpatient physiotherapy after medial meniscectomy.

In a randomised controlled trial comparing the outcome of two groups of men aged 16-45 one group received outpatient physiotherapy after medial meniscectomy and the other did not. In clinical aspects of knee function there was no significant difference between the test group and control group measured at specified intervals up to 26 weeks postoperatively. Similarly, there was no significant difference between the groups in the time taken to return to work or in the mean fall in take-home pay as a result of meniscectomy. The mean cost per patient of providing outpatient physiotherapy in the test group was 23 pounds at 1976 prices. Thus the least costly way of returning male patients aged 16-45 to activity is by not providing routine outpatient physiotherapy after medial meniscectomy. Further randomised controlled trials are, however, required to determine the value of physiotherapy in other age groups and other conditions.

Health and education expenditure in the United Kingdom: what priority?

Public expenditure on goods and services per head of population on the National Health Service (NHS) in the United Kingdom has risen less rapidly than some other forms of public expenditure such as education. Revenue expenditure at 1970 market prices on goods and services in the NHS per head of population rose by 38% during the period 1951 to 1968. During the same time interval, expenditure at 1970 market prices on goods and services in education per head of population rose by 84%. Health, as measured by standardised mortality ratios (SMRs), improved over a similar period. This paper argues that, in the long term, the priority given to education expenditure may not necessarily be detrimental to further improvements in community health.

Met and unmet demand for hospital beds. Some recent evidence.

Many commentators have noted the interrelation of demand and supply of hospital beds and have suggested that an increase in the supply of hospital beds tends to generate additional demand either in the form of more patients admitted or patients treated for longer periods of time or some combination of the two. We can report that the bed use rate can be predicted more accurately in terms of the five-seventh rule, that is if a National Health Service bed is made available for an additional week, then for five out of seven days it will be occupied. This rule was found to apply at both regional and district level. Variation in admission rates was also investigated and it was found that a large proportion of the observed variation could be explained in terms of one variable--bed supply. In view of the Resource Allocation Working Party's proposals, the relationship between the overall standardized mortality ratio and bed supply, admissions rate and bed use rate was investigated. No significant effect, however, was discovered. In other words, it is bed supply which strongly influences the demand for hospital care and not the overall standardized mortality ratio.