Gender diversity in therapeutic radiography: A mixed methods exploration of the gender influences impacting on male students' career choices.

INTRODUCTION: A significant gender imbalance exists in therapeutic radiography, with male radiographers contributing to less than one fifth of the UK registered workforce. This research aimed to explore male student recruitment experiences to identify gender-sensitive strategies to employ within future recruitment drives. METHODS: An exploratory mixed methods design commenced with therapeutic radiography student focus groups, analysed via descriptive thematic analysis. The focus group themes informed an online questionnaire survey targeting enrolled male therapeutic radiography students in the UK. Both phases explored students' experiences of their career choice and the impact, if any, their gender had on this selection. RESULTS: Three focus groups (n = 9) yielded four major themes: the invisible profession; career choices; gender influences; gender-sensitive approaches. Survey responses (n = 38) represented 9 UK institutions, a 25% estimated response rate. Over half (55%) had little or no awareness of the career at entry, with many discovering the profession 'by accident'. Many had never seen recruitment materials; 40% (n = 15) stated they were not designed to appeal to male applicants, with 18% (n = 7) suggesting they reflected more stereotypical female traits. CONCLUSION: Targeting gender imbalances is always controversial but doing nothing will maintain the status quo and perpetuate an unrepresentative workforce. Earlier awareness-raising of therapeutic radiography is essential, with promotional imagery suitable for different audiences and focusing equally on care and technology. Recruitment language should embrace 'leadership' attributes as well as 'caring' attributes. Supported by male role models, outreach events should emphasise the profession in terms of a sustainable, fulfilling and rewarding career. IMPLICATIONS FOR PRACTICE: The findings have provided detailed recommendations on which to focus a specific recruitment and marketing strategy to encourage male applicants to consider a career in therapeutic radiography.

Meeting the challenges of wound care in Danish home care.

OBJECTIVE: To evaluate a community-based educational intervention to improve wound-care practice, and thereby reduce the costs of care, in four communities in Denmark. METHOD: Annual wound care audits recorded patients' ages, the number and types of wounds being treated, wound duration (days unhealed), frequency of dressing changes and nurse time per dressing change. Data were available at year 1 and year 3 post-intervention. A statistical analysis was performed, testing for changes in a range of variables between these years. RESULTS: In the post-intervention period, significant reductions were found in the proportion of chronic wounds, the proportion of wounds requiring a daily dressing change, mean frequency of dressing change, mean nurse time spent in wound care per week, and the total cost of wound care per week. CONCLUSION: These results suggest that it is possible to improve wound-care practice and reduce the resource costs of wound care through a systematic programme of education and training, tailored to suit the needs of local communities.

The cost of pressure ulcers in the United Kingdom.

OBJECTIVE: To provide an estimate of the costs of treating pressure ulcers in the UK at August 2011 prices, as a means of highlighting the importance of pressure ulcer prevention. METHOD: Resource use was derived from a bottom-up methodology, based on the daily resources required to deliver protocols of care reflecting good clinical practice, with prices reflecting costs to the health and social care system in the UK. This approach was used to estimate treatment costs per episode of care and per patient for ulcers of different severity and level of complications. RESULTS: The cost of treating a pressure ulcer varies from £1,214 (category 1) to £14,108 (category IV). Costs increase with ulcer severity because the time to heal is longer and the incidence of complications is higher in more severe cases. CONCLUSION: Pressure ulcers represent a significant cost burden in the UK, both to patients and to health-care providers. Without concerted effort, this cost is likely to increase in the future as the population ages. The estimates reported here provide a basis for assessment of the cost-effectiveness of measures to reduce the incidence of hospital-acquired ulcers. DECLARATION OF INTEREST: Heron Evidence Development Ltd. was funded for this work by Mölnlycke Health Care (UK). The authors have no other conflicts of interest to declare.

The resource impact of wounds on health-care providers in Europe.

Most of the literature focuses on the resources required to manage particular wound types, rather than the cost of wounds to health-care organisations. Until this information is available, wound care is unlikely to be a management priority.

The resource costs of wound care in Bradford and Airedale primary care trust in the UK.

OBJECTIVE: To estimate the resource costs of providing wound care for the 488,000 catchment population of the Bradford and Airedale primary care trust (PCT). METHOD: A wound survey was carried out over a one-week period in March 2007 covering three hospitals in two acute trusts, district nurses, nursing homes and residential homes within the geographical area defined by the PCT. The survey included information on the frequency of dressing change, treatment time and district nurse travel time. The resource costs of wound care in the PCT were estimated by combining this information with representative costs for the UK National Health Service and information on dressing spend. RESULTS: Prevalence of patients with a wound was 3.55 per 1000 population. The majority of wounds were surgical/trauma (48%), leg/foot (28%) and pressure ulcers (21%). Prevalence of wounds among hospital inpatients was 30.7%. Of these, 11.6% were pressure ulcers, of which 66% were hospital-acquired. The attributable cost of wound care in 2006-2007 was pounds 9.89 million: pounds 2.03 million per 100,000 population and 1.44% of the local health-care budget. Costs included pounds 1.69 million spending on dressings, 45.4 full-time nurses (valued at pounds 3.076 million) and 60-61 acute hospital beds (valued at pounds 5.13 million). CONCLUSION: The cost of wound care is significant. The most important components are the costs of wound-related hospitalisation and the opportunity cost of nurse time. The 32% of patients treated in hospital accounted for 63% of total costs. Putting in place care pathways to avoid hospitalisation and avoiding the development of hospital-acquired pressure ulcers and other wound complications are important ways to reduce costs. DECLARATION OF INTEREST: John Posnett is an employee of Smith & Nephew.

The cost-effectiveness of fondaparinux compared with enoxaparin as prophylaxis against thromboembolism following major orthopedic surgery.

BACKGROUND: The selective antithrombotic fondaparinux is more effective than the low-molecular-weight heparin enoxaparin for prevention of venous thromboembolism (deep-vein thrombosis [DVT] or pulmonary embolism) in patients undergoing major orthopedic surgery, but its cost-effectiveness is undetermined. OBJECTIVES: To evaluate the cost-effectiveness of fondaparinux relative to enoxaparin as prophylaxis against venous thromboembolism (VTE) for patients undergoing total hip replacement, total knee replacement or hip fracture surgery in the UK. PATIENTS/METHODS: A decision analysis model was created simulating the impact of fondaparinux and enoxaparin on patient outcomes and costs over various time points up to 5 years following surgery. The main outcome measures were treatment costs per patient and the incidence of clinical VTE and VTE-related deaths. A weighted (combined) cohort reflects the proportion of patients undergoing these procedures in 2000/2001. RESULTS: In the combined cohort, compared with enoxaparin, fondaparinux is expected to produce 20 fewer clinical VTE events and 3.2 fewer VTE-related deaths per 1000 procedures at 5 years. Cost savings at 5 years are pound 27 per patient with fondaparinux (discounted at 6% per year). In each of the three surgical groups, fondaparinux leads to lower expected costs per patient and to a smaller number of VTE events and VTE-related deaths. RESULTS are sensitive to the price difference between fondaparinux and enoxaparin and variation in the rate of late DVT. The analysis is robust to variations in all other key parameters. CONCLUSIONS: Compared with enoxaparin, fondaparinux is more effective and reduces costs to the healthcare system. At current prices, fondaparinux is the recommended strategy in the UK for prophylaxis following major orthopedic surgery.

Team approach versus ad hoc health services for young people with physical disabilities: a retrospective cohort study.

BACKGROUND: Young people with physical disabilities often have difficulty attaining independence in adult life and consequently need lifelong support from parents and from health-care and social-care services. There are concerns about the organisation and cost-effectiveness of such services and their ability to meet the independence training and serious health needs of these young people. Our aim was to compare a young adult team (YAT) approach with the ad hoc service approach in four locations in England, in terms of their ability to enhance the participation in society of these young people and their cost. METHODS: We did a retrospective cohort study, in which we interviewed 254 physically disabled young people. 124 healthy controls were given a questionnaire. We interviewed with standardised measures and used logistic regression analysis to test for effects of ad hoc and YAT services. The Mantel-Haenszel chi2 statistic was used to test for differences in resource use between areas in which the YAT and ad hoc services were available. FINDINGS: The absence of pain, fatigue, and stress increased the odds of participation two-fold to four-fold. After adjustment for these factors, young people cared for by multidisciplinary YAT teams were 2.54 times (95% CI 1.30-4.98) more likely than those who used ad hoc services to participate in society. Resource use did not differ between the two service types. INTERPRETATION: A YAT approach costs no more to implement than an ad hoc approach, and is more likely to enhance participation in society of young people with physical disabilities.

Does general practitioner involvement in commissioning maternity care make a difference?

OBJECTIVES: To evaluate the impact of general practitioners' commissioning of maternity services on women's experiences of care and on resource use, and to consider the implications for primary care commissioning. METHOD: Comparison of women's experiences and resource use between 11 commissioning and 10 non-commissioning general practices. Face-to-face interviews with 212 staff in general practices, National Health Service trusts and health authorities between 1996 and 1998 to establish how maternity care was organised. Women's experience of information, choice, control and resource use obtained by questionnaire mailed 4 weeks post-partum. Data were analysed using multi-level modelling to adjust for case-mix differences. RESULTS: After two reminders, 1957 women (62%) responded to the questionnaire (inter-practice range 52-81%). There were no significant differences in women's experience of care or their resource use between commissioning and non-commissioning practices. Commissioning practices were more likely to be associated with more vertically integrated models of service organisation, but responses to only three of 21 questions about experience of information, choice and control over care, or about resource use, differed between the four models of service organisation identified. CONCLUSIONS: The expectation that giving primary care organisations responsibility for commissioning care will result in improved patients' experiences of care or better use of resources should be treated with caution. The presence of strong national policy may be equally important. Models of service organisation are not proxies for quality of care. The most powerful force shaping patients' experiences of care may be health care professionals' ability to translate national policy into local services.

Cost-effectiveness modeling of Dermagraft for the treatment of diabetic foot ulcers in the french context.

To assess the cost-effectiveness of Dermagraft(R) (human dermal replacement) in the treatment of the diabetic foot ulcer, compared to standard treatment. A Markov model was developed, to simulate, over a 52-week period, the health status of a cohort of 100 patients with a diabetic foot ulcer treated either with conventional therapy or with Dermagraft(R). The considered health states were: healed, same site recurrence, unhealed not infected, cellulitis, osteomyelitis, amputation and death. Each week, the patient may progress among states according to a set of transition probabilities directly derived from the original clinical trial conducted in the USA. The cost of each health state was estimated by a Delphi panel of French diabetologists (direct costs only, valuated from a societal perspective). A sensitivity analysis was performed. The total number of healed ulcers included first ulcers healed (76.38% for Dermagraft(R) vs. 69.35% for standard treatment; median time to heal is 14-15 weeks for Dermagraft(R) compared with 28-29 weeks for standard treatment) plus recurrences which are subsequently healed within the 52-week period (14.29 for Dermagraft(R) vs. 25.09 for standard treatment; median time to heal is 3-4 weeks for Dermagraft(R) compared with 5-6 weeks for standard treatment). The average expected cost per treated patient (C/E) using standard treatment for the considered 52-week period is 47,418 FF vs. 54,384 FF for Dermagraft(R) (including 18,200 FF for Dermagraft(R) acquisition and 36,184 FF for standard treatment). Because Dermagraft(R) heals more ulcers within 52 weeks, the average cost per healed ulcer is lower (53,522 FF vs. 56,687 FF for standard treatment). The incremental cost-effectiveness ratio of Dermagraft(R) (DeltaC/DeltaE) equals 38,784 FF, indicating the extra investment that the decision-maker has to accept for an additional ulcer healed with Dermagraft(R) compared with conventional treatment.

Evaluation of the relative cost-effectiveness of treatments for infertility in the UK.

This paper aims to complement existing clinical guidelines by providing evidence of the relative cost-effectiveness of treatments for infertility in the UK. A series of decision-analytical models have been developed to reflect current diagnostic and treatment pathways for the five main causes of infertility. Data to populate the models are derived from a systematic review and routine National Health Service activity data, and are augmented with expert opinion. Costs are derived from an analysis of extra-contractual referral tariffs and private sector data. Sensitivity analysis has been carried out to take account of the uncertainty of model parameters and to allow results to be interpreted in the light of local circumstances. Results of the modelling exercise suggest in-vitro fertilization is the most cost-effective treatment option for severe tubal factors and endometriosis, with surgery the most cost-effective in the case of mild or moderate disease. Ovulatory factors should be treated medically with the addition of laparoscopic ovarian diathermy in the presence of polycystic ovarian syndrome. For other causes, stimulated intrauterine insemination (unexplained and moderate male factor) and stimulated donor intrauterine insemination (severe male) are cost-effective.

Comparative cost-effectiveness of four-layer bandaging in the treatment of venous leg ulceration.

This paper reports the results of an analysis designed to estimate the expected annual cost per patient of treating venous leg ulcers, and to evaluate the relative cost-effectiveness of a systematic treatment regimen using a four-layer compression bandaging system (Profore) compared with usual care. A Markov model has been developed which simulates the transition of patients between health states (healed and unhealed) over a 52-week period. Healing rates used in the model are derived from those reported in the literature. By running the model for a cohort of 100 patients over 52 weeks it is possible to estimate expected outcomes and annual budgetary costs for alternative treatment regimens. Results suggest that, when compared with usual care, a systematic treatment regimen using Profore is unambiguously more cost-effective. Patient outcomes are improved and annual treatment costs reduced. An important implication is that failure to co-ordinate treatment policies and to use the most cost-effective treatments may result in substantial inefficiency in the use of NHS resources. This inefficiency could represent the equivalent of between 350,000 Pounds and 1.08 million Pounds annually for a typical health authority.

Dynamics of bed use in accommodating emergency admissions: stochastic simulation model.

OBJECTIVE: To examine the daily bed requirements arising from the flow of emergency admissions to an acute hospital, to identify the implications of fluctuating and unpredictable demands for emergency admission for the management of hospital bed capacity, and to quantify the daily risk of insufficient capacity for patients requiring immediate admission. DESIGN: Modelling of the dynamics of the hospital system, using a discrete-event stochastic simulation model, which reflects the relation between demand and available bed capacity. SETTING: Hypothetical acute hospital in England. SUBJECTS: Simulated emergency admissions of all types except mental disorder. MAIN OUTCOME MEASURES: The risk of having no bed available for any patient requiring immediate admission; the daily risk that there is no bed available for at least one patient requiring immediate admission; the mean bed occupancy rate. RESULTS: Risks are discernible when average bed occupancy rates exceed about 85%, and an acute hospital can expect regular bed shortages and periodic bed crises if average bed occupancy rises to 90% or more. CONCLUSIONS: There are limits to the occupancy rates that can be achieved safely without considerable risk to patients and to the efficient delivery of emergency care. Spare bed capacity is therefore essential for the effective management of emergency admissions, and its cost should be borne by purchasers as an essential element of an acute hospital service.

Is hospital performance related to expenditure on management?

OBJECTIVES: Reducing the costs of management appears an easy target for those seeking to generate savings or to promote better spending in the National Health Service (NHS). However, an assessment of the appropriate amount of spending on management requires an evaluation of how much management contributes to organizational performance. METHODS: Using routinely available NHS acute hospital data, an econometric analysis was undertaken to test the hypothesis that there is a relationship between the proportion of a hospital's income spent on management and the performance of the hospital measured along three dimensions: the achievement of financial targets; performance against waiting time standards defined in the Patient's Charter; and costs of service provision. RESULTS: No general relationship was found between management costs and hospital performance. However, there was some evidence of a quadratic relationship between management spending and the amount of operating surplus generated and performance against the three-month waiting time standard for an inpatient admission specified in the Patient's Charter. These results suggest that performance returns reach an optimum when management expenditure is around 5-6% of hospital income. CONCLUSIONS: The evidence is not yet strong enough to draw a general conclusion that management costs in NHS acute hospitals are too high or that an undiscriminating reduction in management costs would have no detrimental effects on hospital performance. However, the findings should prompt managers to identify ways in which their activities are productive and how these can be measured, and what distinguishes effective from ineffective management.

Primary care groups. Growing pains.

The management costs of primary care groups are likely to be higher than envisaged. Duplication of all functions in all PCGs is likely to be more expensive than current health authority commissioning arrangements. In the long term, the most effective deployment of management costs will depend on deciding which PCG commissions what.

An economic approach to clinical trial design and research priority-setting.

Whilst significant advances have been made in persuading clinical researchers of the value of conducting economic evaluation alongside clinical trials, a number of problems remain. The most fundamental is the fact that economic principles are almost entirely ignored in the traditional approach to trial design. For example, in the selection of an optimal sample size no consideration is given to the marginal costs or benefits of sample information. In the traditional approach this can lead to either unbounded or arbitrary sample sizes. This paper presents a decision-analytic approach to trial design which takes explicit account of the costs of sampling, the benefits of sample information and the decision rules of cost-effectiveness analysis. It also provides a consistent framework for setting priorities in research funding and establishes a set of screens (or hurdles) to evaluate the potential cost-effectiveness of research proposals. The framework permits research priority setting based explicitly on the budget constraint faced by clinical practitioners and on the information available prior to prospective research. It demonstrates the link between the value of clinical research and the budgetary restrictions on service provision, and it provides practical tools to establish the optimal allocation of resources between areas of clinical research or between service provision and research.