Challenges to implementing the national programme for information technology (NPfIT): a qualitative study.

OBJECTIVES: To describe the context for implementing the national programme for information technology (NPfIT) in England, actual and perceived barriers, and opportunities to facilitate implementation. DESIGN: Case studies and in depth interviews, with themes identified using a framework developed from grounded theory. SETTING: Four acute NHS trusts in England. PARTICIPANTS: Senior trust managers and clinicians, including chief executives, directors of information technology, medical directors, and directors of nursing. RESULTS: The trusts varied in their circumstances, which may affect their ability to implement the NPfIT. The process of implementation has been suboptimal, leading to reports of low morale by the NHS staff responsible for implementation. The overall timetable is unrealistic, and trusts are uncertain about their implementation schedules. Short term benefits alone are unlikely to persuade NHS staff to adopt the national programme enthusiastically, and some may experience a loss of electronic functionality in the short term. CONCLUSIONS: The sociocultural challenges to implementing the NPfIT are as daunting as the technical and logistical ones. Senior NHS staff feel these have been neglected. We recommend that national programme managers prioritise strategies to improve communication with, and to gain the cooperation of, front line staff

Cost-Effectiveness of Tdap Vaccination of Adults Aged ≥65 Years in the Prevention of Pertussis in the US: A Dynamic Model of Disease Transmission

Objectives: In February 2012, the Advisory Committee on Immunization Practices (ACIP) advised that all adults aged ≥65 years receive a single dose of reduced-antigen-content tetanus, diphtheria, and acellular pertussis (Tdap), expanding on a 2010 recommendation for adults >65 that was limited to those with close contact with infants. We evaluated clinical and economic outcomes of adding Tdap booster of adults aged ≥65 to “baseline” practice [full-strength DTaP administered from 2 months to 4–6 years, and one dose of Tdap at 11–64 years replacing decennial Td booster], using a dynamic model. Methods: We constructed a population-level disease transmission model to evaluate the cost-effectiveness of supplementing baseline practice by vaccinating 10% of eligible adults aged ≥65 with Tdap replacing the decennial Td booster. US population effects, including indirect benefits accrued by unvaccinated persons, were estimated during a 1-year period after disease incidence reached a new steady state, with consequences of deaths and long-term pertussis sequelae projected over remaining lifetimes. Model outputs include: cases by severity, encephalopathy, deaths, costs (of vaccination and pertussis care) and quality-adjusted life-years (QALYs) associated with each strategy. Results in terms of incremental cost/QALY gained are presented from payer and societal perspectives. Sensitivity analyses vary key parameters within plausible ranges. Results: For the US population, the intervention is expected to prevent >97,000 cases (>4,000 severe and >5,000 among infants) of pertussis annually at steady state. Additional vaccination costs are $4.7 million. Net cost savings, including vaccination costs, are$47.7 million (societal perspective) and $44.8 million (payer perspective). From both perspectives, the intervention strategy is dominant (less costly, and more effective by >3,000 QALYs) versus baseline. Results are robust to sensitivity analyses and alternative scenarios. Conclusions: Immunization of eligible adults aged ≥65, consistent with the current ACIP recommendation, is cost saving from both payer and societal perspectives

Cost-Effectiveness Analysis of Tdap in the Prevention of Pertussis in the Elderly

Objectives: Health benefits and costs of combined reduced-antigen-content tetanus, diphtheria, and pertussis (Tdap) immunization among adults ≥65 years have not been evaluated. In February 2012, the Advisory Committee on Immunization Practices (ACIP) recommended expanding Tdap vaccination (one single dose) to include adults ≥65 years not previously vaccinated with Tdap. Our study estimated the health and economic outcomes of one-time replacement of the decennial tetanus and diphtheria (Td) booster with Tdap in the 10% of individuals aged 65 years assumed eligible each year compared with a baseline scenario of continued Td vaccination. Methods: We constructed a model evaluating the cost-effectiveness of vaccinating a cohort of adults aged 65 with Tdap, by calculating pertussis cases averted due to direct vaccine effects only. Results are presented from societal and payer perspectives for a range of pertussis incidences (25–200 cases per 100,000), due to the uncertainty in estimating true annual incidence. Cases averted were accrued throughout the patient 's lifetime, and a probability tree used to estimate the clinical outcomes and costs (US$2010) for each case. Quality-adjusted life-years (QALYs) lost to acute disease were calculated by multiplying cases of mild/moderate/severe pertussis by the associated health-state disutility; QALY losses due to death and long-term sequelae were also considered. Incremental costs and QALYs were summed over the cohort to derive incremental cost-effectiveness ratios. Scenario analyses evaluated the effect of alternative plausible parameter estimates on results. Results: At incidence levels of 25, 100, 200 cases/100,000, vaccinating adults aged 65 years costs an additional$336,000, $63,000 and$17,000/QALY gained, respectively. Vaccination has a cost-effectiveness ratio less than $50,000/QALY if pertussis incidence is >116 cases/100,000 from societal and payer perspectives. Results were robust to scenario analyses. Conclusions: Tdap immunization of adults aged 65 years according to current ACIP recommendations is a cost-effective health-care intervention at plausible incidence assumptions

Real-world comparison of bleeding risks among non-valvular atrial fibrillation patients prescribed apixaban, dabigatran, or rivaroxaban

Limited real-world data are available regarding the comparative safety of non-vitamin K antagonist oral anticoagulants (NOACs). The objective of this retrospective claims observational cohort study was to compare the risk of bleeding among non-valvular atrial fibrillation (NVAF) patients prescribed apixaban, dabigatran, or rivaroxaban. NVAF patients aged ≥18 years with a 1-year baseline period were included if they were new initiators of NOACs or switched from warfarin to a NOAC. Cox proportional hazards modelling was used to estimate the adjusted hazard ratios of any bleeding, clinically relevant non-major (CRNM) bleeding, and major inpatient bleeding within 6 months of treatment initiation for rivaroxaban and dabigatran compared to apixaban. Among 60,227 eligible patients, 8,785 were prescribed apixaban, 20,963 dabigatran, and 30,529 rivaroxaban. Compared to dabigatran or rivaroxaban patients, apixaban patients were more likely to have greater proportions of baseline comorbidities and higher CHA2DS2-VASc and HAS-BLED scores. After adjusting for baseline clinical and demographic characteristics, patients prescribed rivaroxaban were more likely to experience any bleeding (HR: 1.35, 95% confidence interval [CI]: 1.26-1.45), CRNM bleeding (HR: 1.38, 95% CI: 1.27-1.49), and major inpatient bleeding (HR: 1.43, 95% CI: 1.17-1.74), compared to patients prescribed apixaban. Dabigatran patients had similar bleeding risks as apixaban patients. In conclusion, NVAF patients treated with rivaroxaban appeared to have an increased risk of any bleeding, CRNM bleeding, and major inpatient bleeding, compared to apixaban patients. There was no significant difference in any bleeding, CRNM bleeding, or inpatient major bleeding risks between patients treated with dabigatran and apixaban

Measuring income-related inequalities in health in multi-country analysis

Health inequalities remain a cause of concern for policymakers across the world. However, the measurement and monitoring of health inequalities over time and across countries remain a research challenge. The concentration index is one of the most popular measurement tools, however, it presents several drawbacks, especially for bounded variables, which are discussed in this study. Results from the European Community Household Panel dataset and the Statistics of Income and Living Conditions for Europe suggest that there is evidence of persistent socioeconomic inequalities in health in Europe. Further, results show the need of reporting both absolute and relative inequalities for appropriately monitoring and comparing trends in health inequalities across countries.Las desigualdades en salud siguen siendo prioritarias en la agenda política de los países. Sin embargo, la medida y la monitorización de dichas desigualdades en el tiempo y entre países continúan siendo un desafío para los investigadores. El Índice de Concentración es una de las herramientas más utilizadas; sin embargo, éste presenta limitaciones, especialmente para variables limitadas, que son comentadas en este estudio. Los resultados obtenidos a partir del Panel de Hogares de la Unión Europea y las Estadísticas de Renta y Condiciones de Vida Europea demuestran que existen desigualdades socioeconómicas en salud en Europa persistentes en el tiempo. Además, de los resultados se desprende la necesidad de mostrar las desigualdades tanto absolutas como relativas, para realizar el seguimiento adecuado de las mismas y asimismo, favorecer la comparación de las desigualdades en salud entre países

Inequality in health care use among older people in the United Kingdom: an analysis of panel data

Horizontal equity in health care service use is an area that remains relatively unexamined in the literature on older people. The purpose of this study is to investigate the extent of income-related inequity in the use of GP, inpatient, outpatient and dental services among individuals aged 65 and over in the United Kingdom between 1997 and 2003 using a panel analysis of data from the British Household Panel Survey. The probability of GP, outpatient, dentist or inpatient service use between 1997 and 2003 was predicted using multiple random effects probit panel models, and the estimates used to calculate incomerelated horizontal inequity. The results indicate that individuals on a lower income are significantly less likely to visit a GP, specialist or dentist than the better-off, although they have significantly greater need (the reverse is seen for dental care). However, after adjusting for differences in need, horizontal inequity is found with utilization favouring those on a higher income for all service areas, but not significantly in hospital care

Health inequality: why is it important and can we actually measure it?

Health inequalities are present in most European countries and evidence of widening inequalities is shown in a number of national and international studies. However, the measurement and monitoring of health inequalities over time and across countries is not straightforward since the choice of measure will influence the results. Numerous measurement tools have been developed for measuring health. Results can be affected by not only the choice of indicator but also by the social group for analysis. The focus of the paper is mainly on the relationship between relative and absolute inequalities discussing the role of the statistical artefact