Geographic variation in the treatment of non-ST-segment myocardial infarction in the English National Health Service: a cohort study.

OBJECTIVES: To investigate geographic variation in guideline-indicated treatments for non-ST-elevation myocardial infarction (NSTEMI) in the English National Health Service (NHS). DESIGN: Cohort study using registry data from the Myocardial Ischaemia National Audit Project. SETTING: All Clinical Commissioning Groups (CCGs) (n=211) in the English NHS. PARTICIPANTS: 357 228 patients with NSTEMI between 1 January 2003 and 30 June 2013. MAIN OUTCOME MEASURE: Proportion of eligible NSTEMI who received all eligible guideline-indicated treatments (optimal care) according to the date of guideline publication. RESULTS: The proportion of NSTEMI who received optimal care was low (48 257/357 228; 13.5%) and varied between CCGs (median 12.8%, IQR 0.7-18.1%). The greatest geographic variation was for aldosterone antagonists (16.7%, 0.0-40.0%) and least for use of an ECG (96.7%, 92.5-98.7%). The highest rates of care were for acute aspirin (median 92.8%, IQR 88.6-97.1%), and aspirin (90.1%, 85.1-93.3%) and statins (86.4%, 82.3-91.2%) at hospital discharge. The lowest rates were for smoking cessation advice (median 11.6%, IQR 8.7-16.6%), dietary advice (32.4%, 23.9-41.7%) and the prescription of P2Y12 inhibitors (39.7%, 32.4-46.9%). After adjustment for case mix, nearly all (99.6%) of the variation was due to between-hospital differences (median 64.7%, IQR 57.4-70.0%; between-hospital variance: 1.92, 95% CI 1.51 to 2.44; interclass correlation 0.996, 95% CI 0.976 to 0.999). CONCLUSIONS: Across the English NHS, the optimal use of guideline-indicated treatments for NSTEMI was low. Variation in the use of specific treatments for NSTEMI was mostly explained by between-hospital differences in care. Performance-based commissioning may increase the use of NSTEMI treatments and, therefore, reduce premature cardiovascular deaths. TRIAL REGISTRATION NUMBER: NCT02436187.

ECHO: health care performance assessment in several European health systems.

BACKGROUND: Strengthening health-care effectiveness, increasing accessibility and improving resilience are key goals in the upcoming European Union health-care agenda. European Collaboration for Health-Care Optimization (ECHO), an international research project on health-care performance assessment funded by the seventh framework programme, has provided evidence and methodology to allow the attainment of those goals. This article aims at describing ECHO, analysing its main instruments and discussing some of the ECHO policy implications. METHODS: Using patient-level administrative data, a series of observational studies (ecological and cross-section with associated time-series analyses) were conducted to analyze population and patients' exposure to health care. Operationally, several performance dimensions such as health-care inequalities, quality, safety and efficiency were analyzed using a set of validated indicators. The main instruments in ECHO were: (i) building a homogeneous data infrastructure; (ii) constructing coding crosswalks to allow comparisons between countries; (iii) making geographical units of analysis comparable; and (iv) allowing comparisons through the use of common benchmarks. CONCLUSION: ECHO has provided some innovations in international comparisons of health-care performance, mainly derived from the massive pooling of patient-level data and thus: (i) has expanded the usual approach based on average figures, providing insight into within and across country variation at various meaningful policy levels, (ii) the important effort made on data homogenization has increased comparability, increasing stakeholders' reliance on data and improving the acceptance of findings and (iii) has been able to provide more flexible and reliable benchmarking, allowing stakeholders to make critical use of the evidence.

Costs and consequences of acupuncture as a treatment for chronic pain: a systematic review of economic evaluations conducted alongside randomised controlled trials.

BACKGROUND: The economic burden that chronic pain conditions impose on individuals and society is significant. Acupuncture appears to be a clinically effective treatment for some chronic pain conditions. Given the need for policy decisions to be informed by economic evaluations, the objective of this systematic review was to synthesise data from economic evaluations to determine whether acupuncture for the treatment of chronic pain conditions is good value for money. METHODS: A literature search was conducted using health and economics databases, with additional hand-searching. Economic evaluations conducted alongside randomised controlled trials were eligible. RESULTS: Eight economic evaluations were included in this review, seven cost-utility analyses and one cost-effectiveness analysis. Conditions treated included low back pain, neck pain, dysmenorrhoea, migraine and headache, and osteoarthritis. From the seven cost-utility analyses, acupuncture was found to be clinically effective but cost more. The cost per quality adjusted life year (QALY) gained ranged from £2527 to £14,976 per QALY, below the commonly quoted threshold used by the UK National Institute for Health and Clinical Excellence of £20,000 to £30,000. The one cost-effectiveness study indicated that there might be both clinical benefits and cost savings associated with acupuncture for migraine. There was heterogeneity across the eight trials in terms of professional who provided the acupuncture, style of acupuncture, and country of origin. CONCLUSION: The cost per QALY gained in all seven cost-utility studies was found to be below typical thresholds of willingness to pay. Acupuncture appears to be a cost-effective intervention for some chronic pain conditions.

What are the clinical outcome and cost-effectiveness of endoscopy undertaken by nurses when compared with doctors? A Multi-Institution Nurse Endoscopy Trial (MINuET).

OBJECTIVES: To compare the clinical outcome and cost-effectiveness of doctors and nurses undertaking upper and lower gastrointestinal endoscopy. DESIGN: The study was a pragmatic randomised controlled trial. Zelen's randomisation before consent was used to minimise distortion of existing practice in the participating sites. An economic evaluation was conducted alongside the trial, assessing the relative cost-effectiveness of nurses and doctors. SETTING: The study was undertaken in 23 hospitals in England, Scotland and Wales. In six hospitals nurses undertook both upper and lower gastrointestinal endoscopy, yielding a total of 29 'centres'. The study was coordinated and managed from Swansea. Randomisation, data management and analysis were undertaken at York. Analysis was by intention-to-scope. PARTICIPANTS: Sixty-seven doctors and 30 nurses took part in the study. Of 4964 potentially eligible patients, 4128 (83%) were randomised. Of these, 1888 (45%) were recruited to the study from 29 July 2002 to 30 June 2003. INTERVENTIONS: The procedures under study were diagnostic upper gastrointestinal endoscopy and flexible sigmoidoscopy undertaken by nurses or doctors, with or without sedation, using the preparation, techniques and protocols of participating hospitals. MAIN OUTCOME MEASURES: Primary outcome measure was the Gastrointestinal Symptom Rating Questionnaire (GSRQ). The secondary outcome measures were EuroQol (EQ5D), Gastrointestinal Endoscopy Satisfaction Questionnaire (GESQ), State-Trait Anxiety Inventory (STAI), cost-effectiveness, immediate and delayed complications, quality of examination by blinded assessment of endoscopic video recordings, quality of procedure reports, patients' preferences for operator 1 year after endoscopy, and new diagnoses at 1 year. RESULTS: The two groups were well matched at baseline for demographic and clinical characteristics. Significantly more patients changed from a planned endoscopy by a doctor to a nurse than vice versa, mainly for staffing reasons. There was no significant difference between the two groups in the primary or secondary outcome measures at 1 day, 1 month or 1 year after endoscopy, with the exception of patient satisfaction at 1 day, which favoured nurses. Nurses were significantly more thorough in the examination of stomach and oesophagus, but no different from doctors in the examination of duodenum and colon. There was no significant difference in costs to the NHS or patients, although doctors cost slightly more. Although quality of life measures showed improvement in some scores in the doctor group, this did not reach traditional levels of statistical significance. Even so, the economic evaluation, taking account of uncertainty in both costs and quality of life, suggests that endoscopy by doctors has an 87% chance of being more cost-effective than endoscopy by nurses. CONCLUSIONS: There is no statistically significant difference between doctors and nurses in their clinical effectiveness in diagnostic endoscopy. However, nurses are significantly more thorough in the examination of oesophagus and stomach, and patients are significantly more satisfied after endoscopy by a nurse. Endoscopy by doctors is associated with better outcome at 1 year at higher cost, but overall is likely to be cost-effective. Further research is needed to evaluate the clinical outcome and cost-effectiveness of nurses undertaking a greater role in other settings, to monitor the cost-effectiveness of nurse endoscopists as they become more experienced and to assess, the effect of increasing the number of nurse endoscopists on waiting times for patients, and the career implications and opportunities for nurses who become trained endoscopists. Evaluation of the clinical outcome and cost-effectiveness of diagnostic endoscopy for all current indications is also needed.

The costs and effects of introducing selectively trained radiographers to an A&E reporting service: a retrospective controlled before and after study.

The costs and effects of introducing selectively trained radiographers reporting accident and emergency (A&E) radiographs of the appendicular skeleton in a district general hospital were assessed using a retrospective controlled before and after design. Reference standard reports were compared with a random stratified sample of 200 A&E and 200 general practitioner (GP) reports before and after the intervention. GP reports were used as a non-intervention, non-equivalent control group. An A&E specialist registrar judged whether incorrect A&E reports might have a clinically important effect on patient management. The effect of incorrect A&E reports on outcome was assessed by patient re-attendance to the hospital because of missed abnormalities. The annual, average and incremental costs of radiographers and radiologists reporting A&E radiographs were calculated and a sensitivity analysis was undertaken. The introduction of the radiographers resulted in a 1% (95% CI -7.9 to 5.9) fall in A&E radiograph reporting accuracy and 11% (95% CI -33.7 to 11.3) reduction of cases in which incorrect A&E reports might have a clinically important effect on patient management. Only two A&E reports (one before and one after the intervention) affected patient outcome in that a fracture missed at the first visit resulted in patient re-attendance to the X-ray Department. There was a saving of 361 pounds per annum to the X-ray Department. In conclusion this study provides further evidence that selectively trained radiographers can accurately report A&E plain radiographs and at no additional cost.

Workforce productivity and incentive structures in the UK National Health Service.

The UK National Health Service (NHS) is a labour-intensive service, yet the productivity of one of the largest labour forces in the world has been relatively ignored over the last 50 years. The data available to measure productivity over time are limited and focus on inputs and activity, not outcome. However, what data there are indicate that, despite major increases in NHS funding and staffing, changes in technology and continuous reorganisation of structures, productivity tends to show little or no change over successive decades. The challenges to policy-makers are how to improve the measurement of productivity and how to alter the behaviour of hospital clinicians and general practitioners by reform of incentive structures in the UK NHS.

Disease management. A global cost-containing initiative?

Disease management has been marketed by healthcare industry providers as a way of improving resource allocation in healthcare and containing costs. However, to achieve improved efficiency in healthcare requires the guidelines and protocols in the disease management process to be based on sound evidence of effectiveness and cost effectiveness. This has not always been the case. The approach itself has an inadequate evidence base in terms of randomised controlled trials, other rigorous methods of evaluation and the results of economic evaluation. Disease management can be viewed as an attempt by pharmaceutical companies to undertake forward vertical integration into other parts of the healthcare process. This could reduce uncertainty for purchasers and reduce transaction costs, thereby potentially facilitating both healthcare expenditure control and efficiency. However, such cost savings may be outweighed by a concentration of power in disease management (pharmaceutical) companies, and the exploitation of such power to inflate expenditure and misallocate resources. Disease management must be appraised with care.

Universal coverage and cost control: the United Kingdom National Health Service.

The UK NHS has a number of important strengths. Its costs are relatively low compared to the health care systems of other developed countries due in part to cash limited central budgeting. It is extremely popular with the electorate and surveys show overall satisfaction with the NHS despite some dissatisfaction with waiting lists and a public perception of underfunding. The NHS model of general medical care provided by independent contractors has been acclaimed as "a British success" (General Medical Services Council, 1983). The role of the UK GP combines providing primary care and acting as a gatekeeper to secondary care. This increases equitable access to care for the population and assists in cost containment. As a model, it is currently being emulated in other countries including Sweden and US Health Maintenance Organizations but, as in these countries, the UK primary care model has been evaluated poorly. There are of course continuing weaknesses in the UK health care system. There is insufficient knowledge upon which to base health care services and increase efficiency. In the future, if a knowledge-based health care service is to be created, a considerable amount of research and evaluation is required to identify "what works" in health care (i.e., what is effective) and also the cost effective ways of altering provider behaviour to maximise the amount of health gain which can be achieved using a limited budget. The NHS reforms created a lot of enthusiasm and energy but its effects are difficult to disentangle from the simultaneous increases in funding. There is little evidence from the UK or elsewhere that competition in health care produces efficiency or improvements in resource allocation. Evaluation is required to identify which of the reforms are increasing efficiency. Competition needs to be used with caution and recognised as a mean and not an end in itself. It is remarkable how both clinical practice and health policy reform, in the UK and elsewhere, is poorly evaluated. Medical practice varies substantially locally, regionally, and internationally, e.g., patients with similar age and stage of cancer receive very different levels of radiotherapy across Europe. For most interventions, the appropriate level of treatment may be asserted but is not based on cost effectiveness knowledge. Health policy analysts, like clinicians, make assertions about competition and other health care reforms which are value- rather than knowledge-based. Both groups of decision-makers should be more cautious, informing their choices with research rather than relying on unsubstantiated optimism!

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.

Lessons from international experience in controlling pharmaceutical expenditure. II: Influencing doctors.

This is the second of three papers that review international policies to control spending on drugs and to improve the efficiency of drug use. This paper reviews policies influencing doctors' prescribing of drugs--particularly the use of budgetary restrictions, information and feedback, and guidelines--and evaluates the impact of these policies. Studies evaluating incentive systems are limited, but evidence suggests that providing information on its own will not lead to substantial changes in practice and that more active strategies should be evaluated.

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.

Is there scope for improving the cost-effective prescribing of nonsteroidal anti-inflammatory drugs?

Nonsteroidal anti-inflammatory drugs (NSAIDs) are used widely throughout the world to relieve the symptoms of musculoskeletal disorders, in particular osteoarthritis and rheumatoid arthritis. These drugs have significant adverse effects, including gastrointestinal ulceration and the associated complications of perforation and bleeding. The relative toxicity of competing forms of branded and generic NSAIDs varies considerably. Their acquisition cost also varies considerably, sometimes with relatively more toxic drugs being more expensive. Thus, it may be possible to reduce both adverse effects and pharmaceutical expenditures associated with NSAIDs, if doctors' prescribing behaviour can be changed. A tentative exploration of alternative patterns of NSAID use demonstrates that it may be possible to reduce expenditures on NSAIDs in the UK to below the 1994 level, and reduce adverse events. If prescribing of NSAIDs was reduced by 25%, average dosage reduced by 10% and patients switched to less toxic NSAIDs, up to 86 million pounds sterling could be saved per year in the UK, the number of serious adverse events per year reduced by 189 (from a baseline figure of around 500) and the annual number of gastrointestinal complications reduced by 127 (from a baseline figure of around 315). Such results may be achieved without reductions in the quality of life of patients using these drugs. The available clinical and economic information about NSAIDs is limited, and the publication of numerous poor quality studies has corrupted the knowledge base. Despite these problems, there appears to be enough evidence to indicate that expenditure on NSAIDs could be considerably reduced and significant adverse effects could be avoided if general practitioners were persuaded to change their prescribing behaviour. Inefficient and inappropriate prescribing of these often beneficial, but sometimes dangerous, drugs appears to be wasting scarce UK National Health Service resources and harming patients.

Health care reform: informing difficult choices.

During the last decade, policy makers in a large number of countries have attempted various reforms of their health care systems. Health care reform has been described as a 'global epidemic' (Klein, 1993). All health care reforms consist of very complex policy choices, some of which are examined in this article. After an introductory exploration of ideological issues, the objectives of health care reformers are considered. Three major policy objectives of health care reform are examined: cost containment; efficiency; and, equity. Three types of reform which have been advocated are also considered: public planning; market regulation; and provider-advocated reforms such as a 'basic package' with copayments and alternative means of finance. Finally, appropriate features of efficient health care reform are suggested, addressing explicit policy goals.

Help or hindrance? The role of economics in rationing health care.

The economic evaluation of alternative diagnostic and therapeutic interventions is not merely a help to the processes by which decision makers allocate scarce economic resources, it is an essential ingredient into those rationing processes. Clinicians and other decision makers who advocate the use of effectiveness data alone to determine who will be treated and who will be left in pain and discomfort may perpetuate the inefficient use of resources. Rationing, or resource allocation, in health care must be informed by knowledge of the costs and consequences (effects) or alternative interventions. To ignore the economic element in clinical choices, generates inefficiency, and therefore unethical practice. The great advantage of the economic approach to rationing is that it requires an explicit framework which identifies the costs and benefits of alternative actions in all domains of human action. The combination of explicitness and precision inherent in good economic evaluation can only help in the difficult task of producing further health benefits for patients from the limited resources of the NHS.