Use of economic evidence in the design of Health Improvement Programmes (HImPs)

Introduction 1. In recent years considerable efforts have been made to increase the evidence base for decision making within the NHS. Under the NHS R&D Programme a sizeable percentage of NHS resources have been spent on research, one of the largest programmes of research being in the field of health technology assessment. 2. However, whilst the generation of more research evidence is important, mechanisms still need to be developed to increase its use in NHS decision making. The NHS White Paper of 1997 (paragraph 7.5) pointed out that “there are unjustifiable variations in the application of evidence on clinical and cost-effectiveness”. 3. The concept of the Health Improvement Programme (HImP) was first introduced in “The New NHS. Modern: Dependable” (NHS Executive, 1997). This white paper gave the lead responsibility to health authorities to provide a framework for health and social care provision through multi-agency partnership and in collaboration with the public. One of the main aims of the HImP is to produce action plans based on evidence to address local and national priorities. HImPs cover a three year long cycle and are revised annually. The second phase HImPs ran from April 2000 to April 2003 and these are the focus of this project. 4. To date, a small number of reviews of HImPs have been conducted (Abbott et al, 2000, Arora et at 1999 & 2000, Carruthers et al, 1999) but there has been limited exploration of the role of evidence in relation to the HImP, and no specific effort has been made to examine whether the HImP has proved to be a useful vehicle in arranging provision of care to improve the health of the population, given resource constraints. This report explores the evidence base of these second phase HImPs with particular reference to the contribution of economic evidence. Methods 5. In order to examine the use of evidence in the design of HImPs, a threestage project was undertaken. First, a survey of all English health authorities was conducted to elicit HImP leaders’ views on the use of evidence in the design of their own HImP. Second, 10 individuals involved in the HImP and who worked for different health authorities were interviewed to explore their views on the HImP, the role of evidence and the impact of the HImP. Third, a random sample of 25% of all 2000-2003 HImP documents from the health authorities in England were reviewed in order to investigate whether the health care priorities chosen reflect government objectives and whether there was any evidence of the use of economic evidence in the production of the HImP documents. Findings 6. The main findings were that, first, HImPs are seen as having multiple objectives. Whereas the improvement of health is viewed as the prime objective, other important objectives are to reduce health inequalities and to develop partnerships. 7. Second, the notion of evidence is interpreted broadly. Namely, data drawn from classical research studies and published in the literature, do not encompass the range of inputs to the design of a HImP. Many of the inputs relate to national guidance and local professional opinion, which in turn might be based on data from research studies. 8. Third, basic concepts of economics are well understood, if not always applied. This is partly because the level of access to economic analyses and economics expertise was low. Even where economic studies did exist, it was not clear how they could be interpreted and used. 9. Fourth, local constraints greatly influence the development of HImPs. These constraints include time limitations, lack of certain expertise and the need for political acceptability. These often restricted the extent of the search for, interpretation and use of economic evidence. 10. Finally, most importantly, national guidance from National Service Frameworks (NSFs) and the National Institute for Clinical Excellence (NICE) s very influential in the design of HImPs. Given the constraints at the local level, national guidance was assumed to have a sound evidence base and was usually followed, although sometimes adapted in the light of local circumstances. Therefore, the use of national guidance may be the best route to improving the evidence base of HImPs. Research and policy implications 11. The results of this research lend considerable support to a number of research and policy implications, many of which are already underway. The ain implications are: (i) the evidence base of national guidance should be maintained, if not strengthened; (ii) efforts should continue to generate, synthesise and disseminate evidence on a national level; (iii) quantifiable targets (for health improvement) and the role for evidence in priority setting need to be stressed; (iv) the local role in assembling evidence needs to be clearly defined and adequately resourced; (v) efforts to educate health care professionals in evidence-based medicine and economics should be maintained, or strengthened; (vi) more research should be undertaken into the cost-effectiveness of broader socio-economic interventions to improve health. 12. Finally, the research and policy implications of this study also need to be reviewed in the light of the recently announced organisational changes in the NHS, especially the creation of strategic health authorities and the developing role of PCGs/Ts. In particular, it will be important to ensure that PCGs/Ts have the resources and expertise to gather, synthesise and interpret evidence, including economic evidence. Introduction In recent years considerable efforts have been made to increase the evidence base for decision making within the NHS. Under the NHS R&D Programme a sizeable percentage of NHS resources have been spent on research, one of the largest programmes of research being in the field of health technology assessment. In addition, institutions such as the NHS Centre for Reviews and Dissemination, the Cochrane Collaboration and the National Coordinating Centre for Health Technology Assessment have greatly contributed to the communication of research findings to the NHS. The NHS white paper of 1997 (para 7.5) pointed out that “there are unjustifiable variations in the application of evidence on clinical and cost-effectiveness” (NHS Executive, 1997). This view is echoed by several surveys of NHS decision-makers (Crump et al, 2000, Drummond et al, 1997; Duthie et al, 1999) which showed a generally low uptake of available economic evidence and dentified a number of barriers to its use. At the national level, the advent of the National Institute of Clinical Excellence (NICE) (DH, 1999) provides a vehicle by which clinical and cost-effectiveness evidence can be used in decisions about the use of health care interventions, either through technology appraisal or clinical guidelines development. However, at the local level, within the NHS, it is less clear how appropriate evidence (in particular economic evidence) can be brought to bear on NHS decisions. Under the existing structure, many of the decisions about the use of health care interventions will increasingly be taken by Primary Care Groups (PCGs) and rimary Care Trusts (PCTs). However, most of these will be too small to have a capacity to collect, assimilate and apply evidence. The health authorities’ main mechanism for coordinating health care provision, in partnership with PCGs/PCTs, NHS Trusts and other agencies is the Health Improvement Programme (HImP). Therefore, the objective of the research was to study HImPs in order to investigate the extent to which evidence, in particular economic evidence, had been used in their development.HImP

The Effects of Total Sleep Deprivation on Bayesian Updating

Recent evidence suggests that nearly 25% of U.S. adults (47 million) suffer from some level of sleep deprivation. The impact of this sleep deprivation on the U.S. economy includes direct medical expenses related to sleep deprivation and related disorders, the cost of accidents, and the cost of reduced worker productivity. Sleep research has examined the effects of sleep deprivation on a number of performance measures, but the effects of sleep deprivation on decision-making under uncertainty are largely unknown. In this article, subjects perform a decision task (Grether, 1980) in both a well-rested and experimentally sleep-deprived state. The experimental task allows us to explore the extent to which subjects weight prior odds versus new evidence (i.e., information) when forming subjective (posterior) beliefs of a particular event. Wellrested subjects display a tendency to overweight the evidence in forming subjective posterior probability estimates, which is inconsistent with Bayes rule but possibly consistent with use of a ‘representativeness’ heuristic. In his original Bayes rule experiment, Grether (1980) also found that typical student-subjects overweighted the evidence relative to the prior odds in making posterior assessments. Ironically, behavior following sleep-deprivation is more consistent with the use of Bayes rule, because this treatment significantly reduces the (over)weight that subjects place on the new evidence. Because choice accuracy is not significantly affected by sleep deprivation, the significant difference in estimated decision-model parameters may indicate that the brain compensates under adversity in certain risky choice decision environments.

Modelling the long-term benefits of photodynamic therapy (PDT) with Verteporfin for age-related macular degeneration (AMD)

Age related macular degeneration (AMD) is the leading cause of blindness in the United Kingdom and the rest of the western world. It occurs in 15% to 30% of individuals over 75 years of age. About 15% of these patients develop a more aggressive wet form of the disease that causes severe loss of vision. This report contains estimates of the benefits of photodynamic therapy (PDT) with verteporfin therapy using a modeling approach based on clinical trial data. While this report covers only the effects of the treatment, the model built was customizable so that it could be populated with local cost data. This made it possible to use the model to help inform local formulary decisions.clinical trial, blindness, vision

Bayesian inference of sampled ancestor trees for epidemiology and fossil calibration

Phylogenetic analyses which include fossils or molecular sequences that are sampled through time require models that allow one sample to be a direct ancestor of another sample. As previously available phylogenetic inference tools assume that all samples are tips, they do not allow for this possibility. We have developed and implemented a Bayesian Markov Chain Monte Carlo (MCMC) algorithm to infer what we call sampled ancestor trees, that is, trees in which sampled individuals can be direct ancestors of other sampled individuals. We use a family of birth-death models where individuals may remain in the tree process after the sampling, in particular we extend the birth-death skyline model [Stadler et al, 2013] to sampled ancestor trees. This method allows the detection of sampled ancestors as well as estimation of the probability that an individual will be removed from the process when it is sampled. We show that sampled ancestor birth-death models where all samples come from different time points are non-identifiable and thus require one parameter to be known in order to infer other parameters. We apply this method to epidemiological data, where the possibility of sampled ancestors enables us to identify individuals that infected other individuals after being sampled and to infer fundamental epidemiological parameters. We also apply the method to infer divergence times and diversification rates when fossils are included among the species samples, so that fossilisation events are modelled as a part of the tree branching process. Such modelling has many advantages as argued in literature. The sampler is available as an open-source BEAST2 package (https://github.com/gavryushkina/sampled-ancestors).Comment: 34 pages (including Supporting Information), 8 figures, 1 table. Part of the work presented at Epidemics 2013 and The 18th Annual New Zealand Phylogenomics Meeting, 201

Circuit Synthesis of Electrochemical Supercapacitor Models

This paper is concerned with the synthesis of RC electrical circuits from physics-based supercapacitor models describing conservation and diffusion relationships. The proposed synthesis procedure uses model discretisation, linearisation, balanced model order reduction and passive network synthesis to form the circuits. Circuits with different topologies are synthesized from several physical models. This work will give greater understanding to the physical interpretation of electrical circuits and will enable the development of more generalised circuits, since the synthesized impedance functions are generated by considering the physics, not from experimental fitting which may ignore certain dynamics

Better Mouse Traps: The History of their Development in the USA

Out of a total of 165 patented and manufactured mouse traps considered within the context of the USA Patent Office\u27s classification system of animal traps, 7 \u27better mouse traps\u27 are identified, described and illustrated. It is also revealed how only three of these better mouse traps gave rise to most of the very large number of differently named mouse traps that are currently available from a variety of manufacturers for use by both householders and pest control companies

Spin entanglement, decoherence and Bohm's EPR paradox

We obtain criteria for entanglement and the EPR paradox for spin-entangled particles and analyse the effects of decoherence caused by absorption and state purity errors. For a two qubit photonic state, entanglement can occur for all transmission efficiencies. In this case, the state preparation purity must be above a threshold value. However, Bohm’s spin EPR paradox can be achieved only above a critical level of loss. We calculate a required efficiency of 58%, which appears achievable with current quantum optical technologies. For a macroscopic number of particles prepared in a correlated state, spin entanglement and the EPR paradox can be demonstrated using our criteria for efficiencies η > 1/3 and η > 2/3 respectively. This indicates a surprising insensitivity to loss decoherence, in a macroscopic system of ultra-cold atoms or photons

Supersonic combustor modeling

The physical phenomena involved when a supersonic flow undergoes chemical reaction are discussed. Detailed physical models of convective and diffusive mixing, and finite rate chemical reaction in supersonic flow are presented. Numerical algorithms used to solve the equations governing these processes are introduced. Computer programs using these algorithms are used to analyze the structure of the reacting mixing layer. It is concluded that, as in subsonic flow, exothermic heat release in unconfined supersonic flows retards fuel/air mixing. Non mixing is shown to be a potential problem in reducing the efficiency of supersonic as well as subsonic combustion. Techniques for enhancing fuel/air mixing and combustion are described