The unavoidable costs of ethnicity : a review of evidence on health costs

This report was commissioned by the Advisory Committee on Resource Allocation (ACRA), and prepared by the Centre for Health Services Studies (CHESS) and the Centre for Research in Ethnic Relations (CRER) at the University of Warwick. The NHS Executive does not necessarily assent to the factual accuracy of the report, nor necessarily share the opinions and recommendations of the authors. The study reviews the evidence concerning the degree to which the presence of populations of minority ethnic origin was associated with ‘unavoidable additional costs’ in health service delivery. While local health authorities retail full autonomy in their use of funds allocated to them under the Hospital and Community Health Services formula, the size of that budget is governed by a set of weightings applied to their population, to allow for factors known to influence levels of need, and the costs of providing services. The study began by considering the definitions used in describing ‘ethnicity’ and ethnic groups in relevant medical and social policy literature. It is clear that no fixed set of terms can be adopted, and that flexibility is required to respond to social changes. The terms used in the 1991 Census, with additions to allow for local and contemporary developments, provide a suitable baseline but require additional information on religion language and migration history for clinical and health service delivery planning. There have been notable developments in health service strategy to meet the needs of black and minority ethnic groups which have been encouraged by good practice guidelines and local initiatives. Together with research into epidemiology and ethnic monitoring of services, these have enlarged understanding of the impact of diversity. A conceptual model is developed which explores the potential for such diversity to lead to variations in the cost of providing health services to a multi-ethnic population. The research team reviewed the existing published evidence relating to ethnic health and disease treatment in medical, social science, academic and practitioner literature, using conventional techniques. Additional evidence was located through trawls of ‘grey’ literature in specialist collections, and through contacting all English health districts with a request for information. A number of authorities and trusts provided written and oral evidence, and a bibliography of key materials is provided. Key issues considered include the need for and use of, interpreter and translation services, the incidence of ‘ethnically-specific’ disease, and variations in the prevalence and cost of treating ‘common’ conditions in minority ethnic populations. Sources of variation are discussed, and a ‘scoping’ approach adopted to explore the extent to which these variations could be adequately modelled. It is clear that while some additional costs can be identified, and seen to be unavoidable, there are other areas where the presence of minority populations may lead to lessened pressures on budgets, or where provision of ‘ethnic-specific’ facilities may be alternative to existing needs. The literature provides a range of estimates which can be used in a modelling exercise, but is deficient in many respects, particularly in terms of precise costs associated with procedure and conditions, or in associating precise and consistent categories of ethnic group with epidemiological and operational service provision data. Certain other activities require funding to set them up, and may not be directly related to population size. There is considerable variation in the approaches adopted by different health authorities, and many services are provided by agencies not funded by NHS budgets. The study was completed before the announcement of proposed changes in health service commissioning which may have other implications for ethnic diversity. The presence of minorities is associated with the need to provide additional services in respect of interpreting and translation, and the media of communication. In order to achieve clinical effectiveness, a range of advocacy support facilities or alternative models of provision seem to be desirable. Ethnic diversity requires adaptation and additional evidence in order to inform processes of consultation and commissioning. Minority populations do create demands for certain additional specific clinical services not required by the bulk of the majority population: it is not yet clear to what extent the reverse can be stated since research on ‘under-use’ is less well developed. Some variations in levels of need, particularly those relating to established clinical difference in susceptibility or deprivation, are already incorporated in funding formulae although it is not clear how far the indicators adequately reflect these factors. Costs are not necessarily simply related to the size of minority populations. The provision of services to meet minority needs is not always a reflection of their presence, but has frequently depended upon the provision of additional specific funds. There is a consensus that the NHS research and development strategy should accept the need for more work to establish the actual levels of need and usage of service by ethnic minority groups, and that effort should be made to use and improve the growing collection of relevant information through ethnic monitoring activities. A variety of modelling techniques are suggested, and can be shown to have the potential to provide practical guidance to future policy in the field. Current data availability at a national or regional scale is inadequate to provide estimates of the ‘additional costs of ethnicity’ but locally collected data and the existence of relevant policy initiatives suggest that a focused study in selected districts would provide sufficiently robust information to provide reliable estimates. The review has demonstrated that there are costs associated with the presence of minority ethnic groups in the population which can be shown to be unavoidable and additional, but that others are either ‘desirable’ or ‘alternative’. It would be wrong to assume that all cost pressures of this nature are in the same direction. Our study has drawn attention to deficiencies in data collection and budgeting which may hinder investigation of the effectiveness of the service in general. The process of drawing attention to ethnic minority needs itself leads to developments in services which are functional and desirable for the majority population

An integrated care pathway for menorrhagia across the primary–secondary interface : patients' experience, clinical outcomes, and service utilisation

Background: ‘‘Referral’’ characterises a significant area of interaction between primary and secondary care. Despite advantages, it can be inflexible, and may lead to duplication. Objective: To examine the outcomes of an integrated model that lends weight to general practitioner (GP)-led evidence based care. Design: A prospective, non-random comparison of two services: women attending the new (Bridges) pathway compared with those attending a consultant-led one-stop menstrual clinic (OSMC). Patients’ views were examined using patient career diaries, health and clinical outcomes, and resource utilisation. Follow-up was for 8 months. Setting: A large teaching hospital and general practices within one primary care trust (PCT). Results: Between March 2002 and June 2004, 99 women in the Bridges pathway were compared with 94 women referred to the OSMC by GPs from non-participating PCTs. The patient career diary demonstrated a significant improvement in the Bridges group for patient information, fitting in at the point of arrangements made for the patient to attend hospital (ease of access) (p,0.001), choice of doctor (p = 0.020), waiting time for an appointment (p,0.001), and less ‘‘limbo’’ (patient experience of non-coordination between primary and secondary care) (p,0.001). At 8 months there were no significant differences between the two groups in surgical and medical treatment rates or in the use of GP clinic appointments. Significantly fewer (traditional) hospital outpatient appointments were made in the Bridges group than in the OSMC group (p,0.001). Conclusion: A general practice-led model of integrated care can significantly reduce outpatient attendance while improving patient experience, and maintaining the quality of care

Eliciting preferences using discrete choice experiments in healthcare : willingness to pay, stakeholder preferences, and altruistic preferences.

Chapter 1 of the thesis is divided into 5 sections. Section A begins by defining a Discrete Choice Experiment (DCE), and outlines the key stages involved in conducting a DCE. Sections B and C outline theories underpinning DCE analysis. Section B outlines the characteristics theory of demand, whilst section C, explains random utility theory (RUT), compensating variation (CV), marginal willingness to pay (MWTP), and willingness to pay (WTP) analysis. Section D of the thesis provides a review of the DCE literature. Section E outlines the research questions addressed in the thesis including calculating WTP and hypothetical bias; the description of the cost attribute; preference heterogeneity; and altruism. Chapter 2 shows how DCEs can be used to calculate WTP, using a DCE relating to Deep Vein Thrombosis (DVT). Chapter 3 uses data from a DCE applied to Menstrual disorder and Gynaecology patients. It evaluates an experimental method I developed to establish whether respondents might fail to factor in the monetary attribute into their DCE decision making, leading to hypothetical bias. Chapter 4 applies essentially the same DCE design but only analyses data from Gynaecology patients. Chapters 4-8 all use data obtained from a DCE relating to preferences for different allocation criteria for allocating kidneys for transplantation. Chapters 5 and 6 look at preference heterogeneity which is observable using interaction dummy variables (the issue of unobserved preference heterogeneity is considered in chapter 7). Chapter 5 establishes how marginal rates of substitution (MRS) differ between different respondent groups including renal patients, healthcare professionals, live donors / relatives of deceased donors, carers, and ethnic minority versus non-ethnic minority patients. Chapter 6 establishes how MRS differs between non-white ethnic minority patients versus other patients; South Asian patients versus other patients; and according to respondent gender. Chapter 7 of the thesis compares results from models which do not cater for unobserved preference heterogeneity, with results from models which do. Initially 2 basic models which do not cater for preference heterogeneity at all (because they do not include dummy variables) are applied including random effects logit and conditional logit. Then models catering for unobserved preference heterogeneity including Mixed Logit and a Latent Class Model (LCM) are used. Finally there is an analysis involving the application of conditional logit with interaction dummy variables. Chapter 8 of the thesis explores how preferences might differ according to how altruistic respondents are. It establishes how respondent preferences differ according to respondent self-disclosed perspective when answering DCEs. In other words whether they claimed to answer the DCE in terms of what would be best for me; what would be best for me and others; or what is best for others. Finally chapter 9 involves a discussion of the findings emerging from the thesis, and draws conclusions about the merits of material contained in it

Group treatments for sensitive health care problems : a randomised controlled trial of group versus individual physiotherapy sessions for female urinary incontinence

Background: The aim was to compare effectiveness of group versus individual sessions of physiotherapy in terms of symptoms, quality of life, and costs, and to investigate the effect of patient preference on uptake and outcome of treatment. Methods: A pragmatic, multi-centre randomised controlled trial in five British National Health Service physiotherapy departments. 174 women with stress and/or urge incontinence were randomised to receive treatment from a physiotherapist delivered in a group or individual setting over three weekly sessions. Outcome were measured as Symptom Severity Index; Incontinence-related Quality of Life questionnaire; National Health Service costs, and out of pocket expenses. Results: The majority of women expressed no preference (55%) or preference for individual treatment (36%). Treatment attendance was good, with similar attendance with both service delivery models. Overall, there were no statistically significant differences in symptom severity or quality of life outcomes between the models. Over 85% of women reported a subjective benefit of treatment, with a slightly higher rating in the individual compared with the group setting. When all health care costs were considered, average cost per patient was lower for group sessions (Mean cost difference £52.91 95%, confidence interval (£25.82 - £80.00)). Conclusion: Indications are that whilst some women may have an initial preference for individual treatment, there are no substantial differences in the symptom, quality of life outcomes or non-attendance. Because of the significant difference in mean cost, group treatment is recommended

2013 Exit Survey of Graduate Students Completing Degrees Fall 2012, Winter 2013, Spring 2013, and Summer 2013: Descriptive Statistics

The 2013 Exit Survey of Graduate Students Completing Degrees continues the Office of Survey Research’s (OSR) survey of graduate students first initiated in 2009. The current survey was administered at the end of each quarter to students completing their graduate degree. This report summarizes responses from students who graduated in Fall 2012, Winter 2013, Spring 2013, and Summer 2013. Of the 266 recipients of this degree during this time, OSR received valid responses from 204, a response rate of 76.7%. Interestingly, while this response rate is higher than those from the Graduate Exit Surveys in the past, Western had fewer total graduate students complete their degrees between Fall 2012 and Summer 2013 than in either of the prior two years resulting in fewer total responses to this survey than in prior years. With the help of the Assistant Dean of the Graduate School, this survey was designed to elicit information on program satisfaction, the frequency and scope of academic interaction on and off campus, barriers to success, and plans for the future. OSR uses a mixture of online and telephone survey methodologies and links survey results with Western’s student records thus expanding their usefulness to researchers and university decision makers. The survey was launched with an e-mail invitation to potential respondents about four weeks prior to the end of each quarter. Follow up e-mail reminders were sent approximately every four days for the subsequent two weeks. Phone call reminders were placed to all non-respondents. The survey was closed immediately prior to commencement exercises. As with any survey, readers should be concerned with sample selection bias; that is bias which arises because survey respondents are not a random selection of the population of survey recipients. While sample selection bias for Western’s graduate exit survey is mitigated through proper survey techniques and limited by a high response rate, its presence should continually be kept in mind when evaluating results. Section A of this document presents basic descriptive statistics that compare all graduates with those who responded to the survey. At the university level, these comparisons reveal that the average respondent is nearly identical to the average graduate. For instance, 13% of respondents are minorities compared to 13% of all graduates. Similar results occur for average age (30.3 years for respondents, 30.7 years for graduates), the number of credit hours attempted (68.9 for respondents and 69.7 for graduates), the average graduate GPA (3.79 for respondents and 3.80 for graduates), and the quarter of graduation. Section B of this report presents all questions asked. Section C presents these questions broken down by college and,Sections D through G are further broken down to the departmental level for departments with enough respondents to prevent identification of individuals. Because CBE has only a single graduate program, we do not break their responses down further than the college level. While we leave it to the reader to determine what is interesting in the survey, here we highlight some of the findings. The first set of questions is geared to understanding students’ background and general satisfaction with their Western graduate school experience. Immediately prior to beginning their Western graduate program 36% of students were in an undergraduate program, 33% were employed in a field related to their graduate program, and 26% were employed in a field different than their program. Results are very similar to prior surveys. Sixty-nine percent of students claimed that, if given the opportunity, they would “probably” or “definitely” select Western again for graduate study, an amount similar to the 2012 survey but a decrease of five percent relative to the 2011 survey. Seventy percent would “probably” or “definitely” recommend Western to someone considering graduate school, a decrease of five percent relative to the prior year and nine percent lower than two years ago. Survey questions also relate to a student’s academic program. For instance, 86% of students reported that the level of academic challenge was “very” or “extremely” important to them and 73% of students claimed they were “satisfied “or “very satisfied “with the level of academic challenge. Perhaps the largest disparity occurred among the 74% of students who claimed that the “quality of instruction” was “extremely important” to them but only 26% of students said they were “very satisfied” with the quality of instruction. Working as a teaching assistant remains an important component of Western’s graduate program. Forty-six percent of respondents reported working as a TA in some capacity while pursuing their graduate degree. In their most recent TA position, respondents reported working an average of 18.5 hours per week. Eleven percent of graduate students taught an independent section of an undergraduate class; among these the median graduate student repeated this experience 6 times while in Western’s graduate program. The average graduate accumulates just over $19,700 in debt from their graduate program, a 10.6$28,300. There is large variation in amounts of student debt incurred between colleges. Graduates of CHSS incur 50% more debt that those of CBE who, in turn, accumulate about twice as much debt than students in CST. Among all graduate students, almost two-fifths hope to work in a school or community college. The remainders are fairly evenly split between non-profit employment, government employment, and pursuing further graduate study. Among those pursuing employment, at the time our survey was conducted, 45% had already received an offer of employment and 85% of those had accepted an offer. One-hundred percent of these had jobs in their field of study. As with all of OSR’s surveys of Western students, the data from this survey is available to campus researchers upon request

Physical activity, motor competence and movement and gait quality: A principal component analysis

ObjectiveWhile novel analytical methods have been used to examine movement behaviours, to date, no studies have examined whether a frequency-based measure, such a spectral purity, is useful in explaining key facets of human movement. The aim of this study was to investigate movement and gait quality, physical activity and motor competence using principal component analysis.MethodsSixty-five children (38 boys, 4.3 ± 0.7y, 1.04 ± 0.05 m, 17.8 ± 3.2 kg, BMI; 16.2 ± 1.9 kg∙m2) took part in this study. Measures included accelerometer-derived physical activity and movement quality (spectral purity), motor competence (Movement Assessment Battery for Children 2nd edition; MABC2), height, weight and waist circumference. All data were subjected to a principal component analysis, and the internal consistency of resultant components were assessed using Cronbach's alpha.ResultsTwo principal components, with excellent internal consistency (Cronbach α >0.9) were found; the 1st principal component, termed “movement component”, contained spectral purity, traffic light MABC2 score, fine motor% and gross motor% (α = 0.93); the 2nd principal component, termed “anthropometric component”, contained weight, BMI, BMI% and body fat% (α = 0.91).ConclusionThe results of the present study demonstrate that accelerometric analyses can be used to assess motor competence in an automated manner, and that spectral purity is a meaningful, indicative, metric related to children's movement quality

In search of clarity about parity

First paragraph: Andy Clark's Supersizing the Mind: Embodiment, Action, and Cognitive Extension (Clark 2008) is, among other things, a characteristically bold and timely defence of the extended mind hypothesis (Clark and Chalmers 1998). According to this hypothesis, which Clark here calls EXTENDED, the physical mechanisms of mind (the material vehicles that realize cognition) sometimes extend beyond the traditional boundaries of skull and skin, such that "actions and loops through nonbiological structure [sometimes count] as genuine aspects of extended cognitive processes" (p. 85). In the brief treatment that follows I cannot hope to engage with everything that is worthy of discussion in Clark's rich and exciting text, so I shall content myself with exploring and assessing a central thread in his argument for EXTENDED. That thread revolves around what is called the parity principle. Here is how that principle is formulated in Supersizing the Mind (p. 77, drawing on Clark and Chalmers 1998, p. 8): If, as we confront some task, a part of the world functions as a process which, were it to go on in the head, we would have no hesitation in accepting as part of the cognitive process, then that part of the world is (for that time) part of the cognitive process. The general idea is this: if there is functional equality with respect to governing intelligent behaviour (for example, in the way stored information is poised to guide such behaviour), between the causal contribution of certain internal elements and the causal contribution of certain external elements, and if the internal elements concerned already qualify as the proper parts of a cognitive trait (system, state, process, mechanism, architecture...), then there is no good reason to deny equivalent status to the relevant external elements. Parity of causal contribution mandates parity of status with respect to the cognitive

A modular approach for automated sample preparation and chemical analysis

Changes in international relations, especially within the past several years, have dramatically affected the programmatic thrusts of the U.S. Department of Energy (DOE). The DOE now is addressing the environmental cleanup required as a result of 50 years of nuclear arms research and production. One major obstacle in the remediation of these areas is the chemical determination of potentially contaminated material using currently acceptable practices. Process bottlenecks and exposure to hazardous conditions pose problems for the DOE. One proposed solution is the application of modular automated chemistry using Standard Laboratory Modules (SLM) to perform Standard Analysis Methods (SAM). The Contaminant Analysis Automation (CAA) Program has developed standards and prototype equipment that will accelerate the development of modular chemistry technology and is transferring this technology to private industry