Screening and economics.

Screening for disease involves expenditure now in order to reap benefits in the future. It is important to understand why future benefits should be discounted in the cost-benefit calculation. The reasons are derived from a societal preference for consumption now over consumption tomorrow, combined with the productivity of capital, which enables goods today to be transformed into more goods tomorrow. It is also necessary to put costs and values on human lives. This is simplified at present in the UK because a highly restrictive immigration policy implies that the net value of the average additional citizen is zero (or even negative). The cost-benefit calculations that are presented must be carried out highly systematically in order to avoid double counting or omission. A computerized spreadsheet is ideal for this purpose.

The use of cost and management information to improve the efficiency of an out patients clinic.

The Project described in this paper was the development of a micro-computerised database of the management of patients presenting to a hospital clinic with abdominal pain. The database contains clinical, resource use and cost information, and was used to aid the consultant in charge to assess and monitor his patterns of management. During the course of this project, and arguably partly because of the information provided, the overall cost per patient fell by 25%. The project was carried out by the Health Services Research Unit at the University of Warwick between 1982 and 1986, the principal investigator being J.A. Stilwell. The collaborating Health Authority was Dudley, and the Consultant Gastroenterologist was Dr A.N. Hamlyn. Finance was provided by the Department of Health and Social Security.

Information for decision makers at hospital laboratory level: an example of a graphical method of representing costs and effects for a replacement automated technology in a haematology laboratory.

The costs and effects on patient management following the introduction of a fully automated blood count analyser have been evaluated for a hospital haematology laboratory in England, during 1985. In the case of the relatively high throughput observed in the laboratory studied, the automated technology was judged to be cheaper if considering laboratory-centred costs alone. But this was no longer necessarily the case once wider costs, including extra medical workload generated for hospital and community physicians, were included. Effects on patient management were measured for all types of patient, including hospital in-patients, out-patients and general practice patients. A graphical method allowing comparison of the costs and effects of the replacement automated system, termed a Technology MAP (Management Awareness Profile) is presented in the paper. MAPs provide a flexible information display which can be tailored to an individual laboratory's situation producing an overall picture of expected costs and effects on patient management following the introduction of a new technology--a full value-in-use assessment. The authors argue that there is a need for a central source of such value-in-use assessments, especially for new medium-priced diagnostic technologies which are likely to become widely spread in Britain.

What do economists measure?

Economics is concerned with the allocation of scarce resources between competing requirements, which in a market economy are measured in terms of finance. Competition for scarce resources is the major problem of health economics.

Microcomputer software to facilitate costing in pathology laboratories.

A software program is described which will enable laboratory managers to calculate, for their laboratory over a 12 month period, the cost of each test or investigation and of components of that cost. These comprise the costs of direct labour, consumables, equipment maintenance and depreciation; allocated costs of intermediate operations--for example, specimen procurement, reception, and data processing; and apportioned indirect costs such as senior staff time as well as external overheads such as telephone charges, rent, and rates. Total annual expenditure on each type of test is also calculated. The principles on which the program is based are discussed. Considered in particular, are the problems of apportioning indirect costs (which are considerable in clinical laboratory work) over different test costs, and the merits of different ways of estimating the amount or fraction of staff members' time spent on each kind of test. The computer program is Crown copyright but is available under licence from one of us (JAS).

Information for managers in hospitals: representing maternity unit statistics graphically.

Staff who organise and run maternity units contribute many statistics to their health authority but do not find it easy to obtain information about their unit from these statistics. Data that are collected routinely, however, can be used to provide each unit with a graphical profile of its activity and resources. The method described here was derived from the personality profiles used by psychologists and allows staff in one unit to assess the outcome, activity, and use of resources in their unit in relation to similar units, to explain some of the differences when these occur, or to highlight potential problems. Examples are taken from a study of maternity units in the West Midlands. It is concluded that the technique can indicate potential problems and usefully be adopted by those who monitor maternity care in districts or hospitals.

The costs of X rays.

A costing system for radiology departments has been developed which runs on a micro-computer and can produce, for about two days' clerical work, a list of average costs for every type of X ray performed in a department. All costs, including capital and radiologists' time, are covered and the system could be used in the development of performance indicators. An example run, in a general hospital in the West Midlands, is given.

Changing demands made by senile dementia on the National Health Service.

In 1976 and 1981 two studies were undertaken to identify the numbers of elderly severely mentally infirm patients receiving care in a range of institutions in Worcestershire and to examine the appropriateness of the special units planned for them. The numbers of planned places matched the totals of patients in care but the nature of the provision was wrong. The new units were planned for able bodied but demented patients, with a relatively low staff/patient ratio. The number of these patients had fallen by one third, being replaced by patients who needed heavy physical nursing care. The new units would not therefore be able to fulfil their planned role of providing cheaper care than did the geriatric or psychiatric hospitals.

Costs of a clinical chemistry laboratory.

The costs of a clinical chemistry laboratory in a district general hospital were studied. The system used has certain advantages over the conventional Cooper Lybrand method. The time taken by technicians to perform tests was more variable than expected and the cost of sample collection was higher than process-cost for many tests. Indirect costs (overheads) were greater than direct costs and there were potential economies of scale. The most time-consuming part of this study was collecting the cost of chemicals and other disposables.

Evaluation of laboratory tests in hospitals.

The use of laboratory tests in the management of 174 randomly selected patients admitted as acute medical emergencies was monitored in detail. The occasions when a test result changed patient management, and the nature of that change, were noted. Tests were classified according to information yielded and the importance of any action taken. For biochemistry alone every test result was costed. A ranking for all tests was produced, in terms of expected actions per test, and for biochemistry a 'value for money' table giving actions per pound spent. Every test request was classified as either discretionary or non-discretionary. The discretionary category was further subdivided into diagnostic and monitoring. The values, in terms of action-producing results, of non-discretionary, diagnostic, and monitoring tests were compared, and this comparison showed that the cost per item of helpful information was about 10 pounds for diagnostic, 23 pounds for monitoring, and 20 pounds for non-discretionary tests. In total, 1790 pounds was spent, and 28 items of unique information were yielded, enabling clinicians to discharge five patients, take seven courses of action which would have had serious consequences if omitted, and 16 actions the omission of which would have led to very serious consequences.

Relative costs of home and hospital confinement.

The first study in a series concerned with the costs of different strategies of maternity care showed the differences between the costs of booked confinement at home, in a GP hospital for 48 hours, and in a consultant obstetric unit for 48 hours to be small. The study costed 1977 home confinements in Dudley and compared them with matched samples of hospital births. The factors that compensated, in the home booked deliveries, for the cost of hospital stay were an average of 11 extra visits from community midwives, midwife attendance for six hours at delivery, and a proportion who were transferred to hospital after receiving the extra antenatal care of a home booked delivery. This differential transfer rate is a crucial factor that merits further investigation. Family-borne costs were included in the study. The most significant was time off work by the husband. Average family costs were 68 pounds, about 30% of public sector costs. Any acceptable strategy of home confinements must provide for last-minute transfers to hospital.

Family-doctor support for patients on a psychiatric case register.

The family-doctor consultations of 76 patients on a psychiatric case register and 76 matched controls were examined. During a two-year period the psychiatric patients consulted just over twice as often as the controls (p < 0.001). Contact with the psychiatric services did not reduce the psychiatric patients' demand for general-practitioner time.

Benefits and costs of the schools' BCG vaccination programme.

By the mid-1980s the schools' BCG vaccination programme will be uneconomic. It is estimated that it will cost about pounds5500 to prevent one case of tuberculosis, the average total cost of which would be between pounds400 and pounds1300 depending on medical policy about the degree of illness for which hospital admission is necessary. In December 1975 the costs of the BCG programme were greater than its monetary benefits, probably by a factor of about 2.