Cost minimisation analysis of using acellular dermal matrix (Strattice™) for breast reconstruction compared with standard techniques.

BACKGROUND: We performed a cost analysis (using UK 2011/12 NHS tariffs as a proxy for cost) comparing immediate breast reconstruction using the new one-stage technique of acellular dermal matrix (Strattice™) with implant versus the standard alternative techniques of tissue expander (TE)/implant as a two-stage procedure and latissimus dorsi (LD) flap reconstruction. METHODS: Clinical report data were collected for operative time, length of stay, outpatient procedures, and number of elective and emergency admissions in our first consecutive 24 patients undergoing one-stage Strattice reconstruction. Total cost to the NHS based on tariff, assuming top-up payments to cover Strattice acquisition costs, was assessed and compared to the two historical control groups matched on key variables. RESULTS: Eleven patients having unilateral Strattice reconstruction were compared to 10 having TE/implant reconstruction and 10 having LD flap and implant reconstruction. Thirteen patients having bilateral Strattice reconstruction were compared to 12 having bilateral TE/implant reconstruction. Total costs were: unilateral Strattice, £3685; unilateral TE, £4985; unilateral LD and implant, £6321; bilateral TE, £5478; and bilateral Strattice, £6771. CONCLUSIONS: The cost analysis shows a financial advantage of using acellular dermal matrix (Strattice) in unilateral breast reconstruction versus alternative procedures. The reimbursement system in England (Payment by Results) is based on disease-related groups similar to that of many countries across Europe and tariffs are based on reported hospital costs, making this analysis of relevance in other countries.

Do community hospitals reduce the use of district general hospital inpatient beds?

Community hospitals have been supported by the general public and by professionals as one means of increasing choice between local, low technology, care and high technology care at the district general hospital. However, there is no information on the impact of community hospitals on district general hospital use subsequent to NHS and community care reforms. Examination of routinely gathered activity data in the Bath Health District revealed that availability of community hospital beds was associated with reduced use of central inpatient services in the city of Bath. The reduction was most apparent for medical and geriatric beds. Decrease in the use of surgical beds was small. However, total inpatient bed use (including central and community hospital beds) was higher in the population with access to community hospital beds. We conclude that community hospitals offer one option for accessible health care and, as such merit systematic evaluation of costs and benefits. This study presents some evidence that savings could be achieved through improved efficiency.

Adding retinal photography to screening for diabetic retinopathy: a prospective study in primary care.

OBJECTIVE: To evaluate whether adding retinal photography improved community screening for diabetic retinopathy. SETTING: Mobile screening unit at rural and urban general practices in south west England. SUBJECTS: 1010 diabetic patients from primary care. DESIGN: Prospective study; patients were examined by ophthalmoscopy by general practitioners or opticians without fundal photographs and again with photographs, and assessments were compared to those of an ophthalmologist. MAIN OUTCOME MEASURES: Whether fundal photography improved the sensitivity of detection of retinopathy and referrable diabetic retinopathy, and whether this sensitivity could be improved by including a review of the films by the specialist. RESULTS: Diabetic retinopathy was detected by the ophthalmologist in 205 patients (20.5%) and referrable retinopathy in 49 (4.9%). The sensitivity of the general practitioners and opticians for referrable retinopathy with ophthalmoscopy was 65%, and improved to 84% with retinal photographs. General practitioners' sensitivity in detecting background retinopathy improved with photographs from 22% to 65%; opticians' sensitivity in detecting background retinopathy improved from 43% to 71%. The sensitivity of detecting referrable retinopathy by general practitioners improved from 56% to 80% with photographs; for opticians it improved from 75% to 88%. CONCLUSIONS: Combining modalities of screening by providing photography with specialist review of all films in addition to direct ophthalmoscopy through dilated pupils improves assessment and referral for diabetic retinopathy by general practitioners and opticians. With further training and experience, primary care screeners should be able to achieve a sensitivity that will achieve an effective, acceptable, and economical community based screening programme for this condition.

Evaluating palliative care education.

This paper illustrates the evaluation of some of the effects of a 3-day workshop for principals and trainees in general practice on a number of aspects of palliative care, using pre-, immediate and late post-tests. Further qualitative evaluation is attempted by including a questionnaire with the late post-test. The evaluation is to demonstrate significant shifts, or differences, in confidence in dealing with physical and psychosocial symptoms, and in participants' perceived ability to cope, and to support these findings with qualitative data where appropriate.

The difficulties of investigating motor vehicle traffic accident mortality in a district.

Many difficulties were experienced in obtaining and using data required to test a series of proposed hypotheses to explain the high standardised mortality ratio (SMR) for motor vehicle traffic accidents (MVTAs) in the Bath District. The authors had expected that, given the importance of MVTAs and the amount of effort put into collecting data by established organisations, it should have been possible to access easily the information required to investigate a district which had a high SMR. The variety of data, collected by the many organisations involved in the problem of road traffic accidents, was expected to assist the investigation. However, in practice the result of the difficulties was that the considerable data collected on MVTAs were not readily usable in the district-based investigation described in this paper. Organisational and definitional reasons are identified to explain the observed difficulties. Several possible solutions are proposed. The responsibility for MVTA prevention should be with a single named authority which could be either the County Council or the District Health Authority. Systems should be organised to allow each district to access easily the statistics relating to accidents involving residents of the district, especially those occurring outside the district of residence. Results of coroners' investigations should also be routinely transferred to the coroner of the district of residence so that information on deaths to all residents of a district can be obtained from a single local source. Given the existing systems and limited resources, the authors concluded that further investigation into the high SMR for MVTAs in the Bath Health District was not justified.(ABSTRACT TRUNCATED AT 250 WORDS)

Public attitudes to charging for some National Health Service services.

This report describes the views of members of the public to proposals to charge for a given list of NHS services for which no charges are currently made. The questions were part of a survey conducted in Cardiff in 1986. The majority of respondents would agree with the suggested charges being levied. This agreement spanned all sections of society. Despite the majority in favour, the sample was divided with a third of respondents being strongly for nearly all the charges and a quarter being strongly against all or all but one of the charges. Most respondents to the survey are judging each charge as a separate issue rather than indicating either approval or disapproval for all cases. If charges for services were to be introduced there could be majority agreement but each charge would have to be considered as a separate issue.

Consultants' views of a district's services.

A postal questionnaire survey of consultants in the Bath Health District was conducted to establish a means for individual consultants to express their views about the provision of health services in the district, so that by working together a new relationship between the District Health Authority (DHA) as purchaser and the clinicians as providers of services could commence. A response rate of 84 per cent was achieved. The survey sought views on clinical and management issues to be used in the development of service agreements (contracts) and views on topics identified by general practitioners (GPs) as areas in need of improvement. Detail is given of results relating to out-patient services, issues of communication and the continuing role of community hospitals. Most consultants sanctioned the appropriateness of referrals by GPs to out-patient services but they identified some out-patient referrals as inappropriate. This justifies a further review of the out-patient services to be purchased by the DHA. Consultants were in agreement that there was scope for review of out-patient follow-ups. They agreed with GPs that discharge summaries could be provided within 24 hours of patient discharge to improve communication with GPs and that consultants should be available by pager to be contacted by GPs, but disagreed with GPs about the feasibility of giving patients on waiting lists a firm admission date at the time of going on the waiting lists. The majority of consultants were in favour of continuing support for community hospitals. They identified overall social value of community hospitals and greater clinical value of out-patient services than in-patient services in community hospitals.(ABSTRACT TRUNCATED AT 250 WORDS)

Public opinion and purchasing.

OBJECTIVES: To explore the use of a questionnaire to obtain representative public opinions on health services. To examine residents' priorities, knowledge, and views on the public's role in decision making. DESIGN: Self administered postal questionnaire. POPULATION: Random sample of 1500 residents in Bath District Health Authority, drawn from electoral registers. MAIN OUTCOME MEASURES: Levels of agreement or disagreement with statements provided and degree of importance given to services and aspects of services. RESULTS: 70 questionnaires were returned unopened. Completed questionnaires were returned by 704 (49.2%) of the 1430 remaining residents. Kidney dialysis was thought very important by 559 (87%) respondents and family planning by only 58 (9%). Public priorities did not seem to reflect value for money. Clear information about treatment was rated as very important by 530 (76%) and comfortable waiting areas by 70 (10%). 372 (53%) of respondents said that they would definitely travel to a hospital outside the district to reduce their wait for surgery. Knowledge of the services provided by the authority and the money available to it was poor. 446 (65%) respondents wanted greater public involvement in decision making. CONCLUSIONS: A postal questionnaire can provide useful information about public priorities and perceptions about the services provided. More information about health services and their costs and benefits should be given to the public to assist greater public participation in decision making.

Assessing hearing problems within a community survey.

Community surveys are increasingly being used as a method of collecting health and lifestyle data. This report describes the use of a simple question on hearing difficulties within such a survey. A systematic sample of 2.5% of the electoral register of the four Parliamentary constituencies of Cardiff, Wales, was drawn. Of the 5145 individuals in the sample, 83% responded. Age and social class explained much of the variability in reported hearing difficulties. A recent fall and cigarette consumption were associated with hearing problems, but the contribution of alcohol consumption while potentially important did not reach statistical significance. This self-administered community survey provided hearing data which are consistent with other specialized studies and is a viable route for the assessment of community needs.

How good are case notes in the audit of radiological investigations?

Audit based on the use of case notes completed in the ordinary course of patient care has not been widely used because of concern about the completeness and adequacy of such records. This paper describes the results of a study carried out to assess whether information contained in case notes was sufficiently reliable to enable clinical effectiveness to be measured. The study examines the extent to which a radiologist and an epidemiologist agree with two experienced clinicians in making retrospective judgements on whether out-of-hours radiological investigations are worthwhile. There was a high measure of agreement; only a relatively small amount of information in the case notes is needed to make valid judgements on clinical performance. The method described here may be applicable to other diagnostic investigations and the results of the study have wide implications for more effective and efficient management of resources within the NHS.

Britain's new market model of general practice: do consumers know enough to make it work?

In 1989 the British Government announced radical plans, now in the process of implementation, for the reform of the National Health Service. The proposals for primary health care imply a market model, insofar as they assume that patients will be active consumers searching out those general practices which best meet their needs. This paper tests one key assumption of this strategy, i.e., that patients have the information required to make such choices. It does so by analysing the data generated by a survey of the health beliefs and practices of 4266 people. The results suggest that British consumers lack the knowledge needed to make market-style choices and that, more generally, policy makers applying the market model to health care should explicitly address the problem of how to create a better informed public.

People's knowledge of health and disease.

A community survey based on the Cardiff electoral register was carried out in 1986. Seven hundred and ten adults were asked 10 open-ended questions about common serious illnesses in the United Kingdom and were given 18 statements about common diseases and asked to state whether they were true or false. This paper reports their responses. Amongst those gaining the highest scores there were more young people, more females, more from social classes I and II and more who had been educated to college or university level. We discuss the implications of the results for patient behaviour and for health education programmes.

Prevalence and treatment of symptoms of rheumatism and arthritis among over 65 year olds: a community profile.

A group of people aged 65 years and over was given a self-completion questionnaire requesting information about symptoms compatible with arthritis and rheumatism. Such symptoms were very common, more so in women than in men and were associated with marked degrees of disability and some dependency. The great majority of respondents said that they regarded their general practitioner as the best person for the treatment of such symptoms, but those with symptoms were slightly less likely than those without to suggest the general practitioner. Many people with symptoms had not reported them to any health service personnel, but had chosen to treat them themselves, suggesting a degree of scepticism about the effectiveness of professional treatment.

Characteristics of self-reported hearing problems in a community survey.

The Cardiff Health Survey included a question asking whether the respondents had any difficulties with their hearing and, if so, to specify the biggest difficulty. This self-completed questionnaire was administered to 4,266 individuals randomly sampled from the electoral register of Cardiff in 1986. 14.7% of those responding indicated a hearing disability; and the main specific disabilities listed are described. The commonest complaints were of difficulties hearing the television and radio, and with general conversation. A number of other specific complaints were reported similar to those found in previous studies with the 'Problems Questionnaire'. Age, social class, general health, smoking and the individual's attitudes were found to influence the pattern of response.

The relationship between dietary habits and beliefs in elderly people compared with younger people.

This study examined the habits and attitudes of a group of people aged 65 and over, in relation to their dietary beliefs and habits when compared with younger individuals. It was found that these older people had similar attitudes to food as those under 65, and these were in line with dietary advice given by health promotion experts. However they had not changed their habits to the same extent, nor did they intend to do so. Reasons for these findings are discussed.

Attitudes of the fit elderly to health issues compared with younger people.

This study examined the habits and attitudes of a group of elderly fit people in relation to health when compared with younger individuals in order to ascertain whether or not a 'successful' group in terms of longevity and morbidity differs from the rest of the adult population. Fit elderly people were, in general, less likely to adhere to standard guidelines for healthy eating than their unfit counterparts or younger age groups.