National primary care research & development centre




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EVIDENCE BASED MEDICINE




Abbott S, et al Evidence-based primary health care and local research: a necessary but problematic partnership. Primary Health Care Research & Development 2008 9 (3) 191-8.

http://dx.doi.org/10.1017/S146342360800073X


Background Front-line NHS staff undertake small research projects to answer questions about local patients and services, but these projects often face considerable challenges. This paper reports on one such project. Aims and methods of study The study used structured interviews in order to find out about the knowledge of nutrition among Bangladeshis using an NHS Walk-in Centre. Development of the study Time constraints posed considerable difficulties in progressing and completing the study; flaws in the methodology emerged; and underpinning assumptions about health promotion and ethnic minority health beliefs were open to challenge .Learning from the study Despite this, some findings were valuable and have considerable potential as a stimulus to critical thinking among practitioners about their own attitudes, as well as raising issues that future research would find it useful to address

Chalkidou K, et al Evidence-informed evidence-making. Journal of Health Services Research and Policy 2008 13 (3) 167-73.

http://dx..doi.org/10.1258/jhsrp.2008.008027

http://pmid.us/18573766

The extent to which clinical and public health guidance developed by the National Institute for Health and Clinical Excellence (NICE) can effectively serve the public by improving quality and efficiency across the National Health Service (NHS) and the broader public sector depends largely on the quality and relevance of the available evidence which informs its decisions. There are well-established organizational and procedural links between NICE and academic and professional organizations that undertake evidence synthesis. However, there are fewer means for evidence gaps identified during the development of NICE guidance to lead to the commissioning of new prospective studies. In this paper, we discuss the importance of a publicly funded clinical and public health research agenda that includes new prospective studies aimed at addressing knowledge gaps identified by NICE. We describe the early experience of NICE and the National Institute for Health Research (NIHR) working together to articulate and commission research to inform best practice recommendations. We propose ways in which NICE can collaborate more effectively with research funders to improve the evidence base upon which it bases its recommendations

HEALTH ECONOMICS






Charlson ME The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patients. Journal of Clinical Epidemiology Online 10/7/ 2008.

http://dx.doi.org/10.1016/j.jclinepi.2008.01.006

http://pmid.us/18619805

Objective: (1) To determine chronic illness costs for large cohort of primary care patients, (2) to develop prospective model predicting total costs over one year, using demographic and clinical information including widely used comorbidity index. STUDY Design and setting: Data including diagnostic, medication, and resource utilization were obtained for 5,861 patients from practice-based computer system over a 1-year period beginning December 1, 1993, for retrospective analysis. Hospital cost data were obtained from hospital cost accounting system. Results: Average annual per patient cost was $2,655. Older patients and those with Medicare or Medicaid had higher costs. Hospital costs were $1,558, accounting for 58.7% of total costs. In the predictive model, individuals with higher comorbidity incurred exponentially higher annual costs, from $4,317 with comorbidity score of two, to $5,986 with score of three, to $13,326 with scores greater than seven. To use an adapted comorbidity index to predict total yearly costs, four conditions should be added to the index: hypertension, depression, and use of warfarin with a weight of one, skin ulcers/cellulitis, a weight of two. Conclusion: The adapted comorbidity index can be used to predict resource utilization. Predictive models may help to identify targets for reducing high costs, by prospectively identifying those at high risk



Dusheiko M, et al Explaining trends in concentration of healthcare commissioning in the English NHS. Health Econ 2008; 17(8):907-926.

http://dx.doi.org/10.1002/hec.1301

http://pmid.us/17935205


In recent years there have been marked changes in organisational structures and budgetary arrangements in the English National Health Service, potentially altering the relationships between purchasers (primary care organisations (PCOs) and general practices) and hospitals. We show that elective admissions from PCOs and practices became significantly more concentrated across hospitals between 1997/98 and 2002/03. There was a reduction in the average number of hospitals used by PCOs (16.7-14.2), an increase in the average share of admissions accounted for by the main hospital (49-69%), and an increase in the average Herfindahl index (0.35-0.55). About half the increase in concentration arose from the increase in the number of purchasing organisations as 100 health authorities were replaced by 303 primary care trusts. Most of the remainder was probably due to hospital mergers. Fundholding general practices that held budgets for elective admissions had less concentrated admission patterns than non-fundholders whose admissions were paid for by their PCO. Around 1/10th of the increase in concentration at practice level was due to the abolition of fundholding in April 1999. Our results have implications for the effects of the recent reintroduction of fundholding and the halving of the number of PCOs

Groot W, Maassen van den Brink H. The value of health. BMC Health Services Research 2008 8 136.

http://dx.doi.org/10.1186/1472-6963-8-136

http://www.biomedcentral.com/1472-6963/8/136

http://pmid.us/18578854


Background: A major problem in cost-effectiveness studies is where to draw the line between interventions which are cost-effective and those who are not. Lacking a notion about the value of a QALY, all ultimate values to the cost-effectiveness ratio are essentially arbitrary. Methods:this paper presents a simple empirical model to estimate the compensating income variation of diseases and health problems. The model is estimated using data for the Netherlands. Results:The compensating income variation is between 20,000 and 90,000 euro. This is higher than most of the ultimate values used by policy-makers to decide whether an intervention is cost-effective. Our figures are roughly similar to those found in studies about the value of a statistical life year. Conclusions :Estimates on the compensating income variation of diseases and health problems may provide useful information on the maximum acceptable cost-effectiveness ratio of medical interventions than those currently used by policy makers

McDonald J, et al The implementation and impact of different funding initiatives on access to multidisciplinary primary health care and policy implications. Medical Journal of Australia. 2008 188 8 (Suppl) S 69-S72.

http://pmid.us/18429741

Objective: To review the implementation and impact of different funding initiatives across the health systems of three different countries - England, New Zealand and Australia - on the achievement of multidisciplinary primary health care (PHC) and to reflect on policy implications for Australia. Methods: A systematic review of the literature involving three stages: (i) identification and description of initiatives; (ii) a systematic review of their implementation and impact from 1995 to mid 2006; and (iii) an updated review of published literature from mid 2006 to mid 2007. Results: Few studies employed control groups, and the results should therefore be interpreted with caution. In all three countries, funding has supported general practitioner access to a broad range of providers. In Australia, financial incentives have been the main mechanism for bringing about change, whereas in both England and New Zealand, they are part of a broader range of funding reforms including the introduction of capitation and practice-based commissioning. The lack of patient data makes it difficult to assess the extent to which the Australian financial incentives have generally improved population access to a broader range of PHC providers. Conclusion: Individual, patient-level, financial incentives may present significant impediments for population subgroups with complex needs. Alternative funding arrangements, such as capitation and contracting, could be more widely adopted in Australia to enhance access to care for vulnerable population groups without fundamentally changing the overall fee-for-service financing arrangements



Martin S, Rice N, Smith PC. Does health care spending improve health outcomes? Evidence from English programme budgeting data. Journal of Health Economics 2008 27 (4) 826-42.


http://dx.doi.org/10.1016/j.jhealeco.2007.12.002

http://pmid.us/18261812

Empirical evidence has hitherto been inconclusive about the strength of the link between health care spending and health outcomes. This paper uses programme budgeting data prepared by 295 English Primary Care Trusts to model the link for two specific programmes of care: cancer and circulatory diseases. A theoretical model is developed in which decision-makers must allocate a fixed budget across programmes of care so as to maximize social welfare, in the light of a health production function for each programme. This yields an expenditure equation and a health outcomes equation for each programme. These are estimated for the two programmes of care using instrumental variables methods. All the equations prove to be well specified. They suggest that the cost of a life year saved in cancer is about ú13,100, and in circulation about ú8000. These results challenge the widely held view that health care has little marginal impact on health. From a policy perspective, they can help set priorities by informing resource allocation across programmes of care. They can also help health technology agencies decide whether their cost-effectiveness thresholds for accepting new technologies are set at the right level


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