Using economic evaluation and preference elicitation methods to inform decisions about how best to reorganise services :a case study of the redesign of emergency medical services

PhD ThesisThe aim of this thesis was to evaluate the centralisation of emergency medical services (EMS) in different local hospitals into a single specialised emergency care hospital in terms of costs and quality of care. It also aimed to investigate preferences and trade-offs that individuals’ were willing to make to receive treatment at the centralised specialised emergency hospital. The economic evaluation method builds upon a systematic review of economic evaluation methods and types of economic evaluation that have been used to assess the performance of centralised healthcare specialities. A discrete choice experiment (DCE) was used to investigate preferences for centralised EMS and the trade-offs individuals were willing to make to receive treatment at the centralised hospital. The DCE identified preferences for: shorter travel times to the hospital; shorter waiting times; fewer days in hospital; low risk of death; low risk of readmission; and outpatient follow-up care in local hospitals. However, people were willing to trade-off increased travel time and waiting time for higher quality of specialised emergency medical care in the centralised hospital. A Markov model was developed to evaluate the costs and effectiveness of centralisation of EMS compared with non-centralised care. Multiple sensitivity analyses were carried out to assess whether centralisation had an impact on cost, quality and cost-effectiveness over the short and longer term. The incremental cost per QALY at one year (deterministic estimate £1,004 per QALY) and 10 years (deterministic estimate £636 per QALY) were both well below the threshold used by the National Institute for Health and Care Health Excellence (£20,000-£30,000 per QALY). There were fewer deaths in the centralised EMS compared with noncentralised services (deterministic estimate: 31.47 fewer deaths at 1 year, 31.57 fewer deaths at 10 years). Discounting the costs and outcomes at different rates did not alter conclusions. The economic evaluation suggested that centralisation of EMS into fewer more specialised units could be cost-effective, although cost-effectiveness may vary in specific population sub-groups. Sub-group analyses suggest that centralised EMS would be more cost-effective for elderly patients, the most economically deprived patients and those presenting with diseases of the circulatory system. These findings ii support the recommendations to centralise urgent and EMS in England. However, a cost benefit analysis that incorporated the results of the DCE into the economic evaluation suggested that centralised EMS could have negative societal value when compared with services provided in local hospitals. The implications of these findings, potential limitations of the methods used in this thesis and recommendations for future research are discussed.Health Foundation Londo

Preferences for centralised emergency medical services: discrete choice experiment

Objectives It is desirable that public preferences are established and incorporated in emergency healthcare reforms. The aim of this study was to investigate preferences for local versus centralised provision of all emergency medical services (EMS) and explore what individuals think are important considerations for EMS delivery. Design A discrete choice experiment was conducted. The attributes used in the choice scenarios were: travel time to the hospital, waiting time to be seen, length of stay in the hospital, risks of dying, readmission and opportunity for outpatient care after emergency treatment at a local hospital. Setting North East England. Participants Participants were a randomly sampled general population, aged 16 years or above recruited from Healthwatch Northumberland network database of lay members and from clinical contact with Northumbria Healthcare National Health Service Foundation Trust via Patient Experience Team. Primary and secondary outcome measures Analysis used logistic regression modelling techniques to determine the preference of each attribute. Marginal rates of substitution between attributes were estimated to understand the trade-offs individuals were willing to make. Results Responses were obtained from 148 people (62 completed a web and 86 a postal version). Respondents preferred shorter travel time to hospital, shorter waiting time, fewer number of days in hospital, low risk of death, low risk of readmission and outpatient follow-up care in their local hospital. However, individuals were willing to trade off increased travel time and waiting time for high-quality centralised care. Individuals were willing to travel 9 min more for a 1-day reduction in length of stay in the hospital, 38 min for a 1% reduction in risk of death and 112 min for having outpatient follow-up care at their local hospital. Conclusions People value centralised EMS if it provides higher quality care and are willing to travel further and wait longer

Technology, Chemistry and Bioactive Properties of Large Cardamom (Amomum Subulatum Roxb.): An Overview.

Large cardamom (Amomum subulatum Roxb.) is an aromatic and medicinal spice native to Eastern Himalayas belonging to the family Zingiberaceae. It is used as flavoring and preservative to different types of coffee, liquors, confections, beverages and tobacco. Volatile oil (2-4%) is the principal aroma-giving compound in large cardamom and 1,8- cineole is the major active compound in an extent 60 to 80% of the total volatile oil. Alcohol and aqueous extract of large cardamom have been reported to contain allopathic, analgesic, anti-inflammatory, antimicrobial, antioxidant, antiulcer, cardio-adaptogenic and hypolipidaemic activities. Large cardamom and its powder, oleoresin and essential oils have many culinary and therapeutic uses. Objective of this review is to give short overview on the processing technology, chemistry, bioactivity and uses of large cardamom and its components

Isolation And Identification Of Dominant Lactic Acid Bacteria From Dahi: An Indigenous Dairy Product Of Nepal Himalayas

Morphological, cultural, physiological and biochemical characteristics were employed to identify dominant Lactic acid bacteria (LAB) isolates from 39 dahi (indigenous dairy product) samples collected from different districts of eastern Nepal. The isolates comprised of predominately Lactobacillus fermentum, Lactobacillus delbrueckii subsp. bulgaricus, Streptococcus thermophilus, Lactococcus lactis subspecies cremoris, Lactococcus lactis subsp. lactis biovar diacetylactis and Leuconostoc mesenteroids subsp. mesenteroids. S. thermophilus were found consistently in most of the samples examined. In this study, 59.38% of Lactobacilli, 21% of Streptococci, 8.2 % Lactococci and 11.42 % Leuconostocs were isolated from indigenous dahi. This study revealed diversity of lactic acid bacteria in Nepalese milieu having immense potential in producing qualitative fermented milk

Economic evaluations on centralisation of specialised healthcare services: a systematic review of methods

Objective - To systematically review and appraise the quality of economic evaluations assessing centralisation of specialised healthcare services. Methods - A systematic review to identify economic evaluations on centralisation of any specialised healthcare service. Full economic evaluations comparing costs and consequences of centralisation of any specialised healthcare service were eligible for inclusion. Methodological characteristics of included studies were appraised using checklists adapted from recommended guidelines. Results - A total of 64 full-text articles met the inclusion criteria. Two studies were conducted in the UK. Most of the studies used volume of activity as a proxy measure of centralisation. The methods used to assess centralisation were heterogeneous. Studies differed in terms of study design used and aspect of centralisation they considered. There were major limitations in studies. Only 12 studies reported the study perspective. Charges which are not true representation of costs were used by 17 studies to assess cost outcomes. Only 10 reported the detailed breakdown of the cost components used in their analysis. Discounting was necessary in 14 studies but was reported only in 7 studies. Sensitivity analyses were included by less than one-third of the studies. The applicability of the identified studies to a setting other than the one they were conducted in is questionable, given variations in the organisation of services and healthcare costs. Centralisation as a concept has also been variably and narrowly defined as activity of specific services which may not reflect the wider aspects of centralisation. Conclusions - Confounded and biased information coming from studies without standardised methods may mislead decision-makers towards making wrong decisions on centralisation. It is important to improve the methodology and reporting of economic evaluations in order to provide more robust and transferable evidence. Wider aspects of healthcare centralisation should be considered in the estimates of costs and health outcomes

The characteristics of the current drug policies in India, Nepal and Bangladesh

The current Indian national drug policy has its roots in two documents originated in the 70-ties and the 80-ties of the XX. century. Although the first National Drug Policy was declared in 1978, it has been revised thrice since then, in 1986, 1994 and 2002. Also, in 1986 another document on the Indian drug policy, titled “Measures for Rationalisation, Quality Control and Growth of Drugs and Pharmaceutical Industry in India” was evolved. The drug policy has been implemented under some legal acts related mainly to the fields of health care, family welfare, scientific research and development, and industry. It emerged from the findings of the Hathi Committee (a committee commissioned to study the operations of multinational drug companies vis-à-vis indigenous companies and public sector undertakings)

COVID-19 Pandemic in the United Kingdom

Objectives To describe epidemiological data on cases of COVID-19 and the spread of Severe Acute Respiratory Syndrome Coronavirus 2 in the United Kingdom (UK), and the subsequent policy and technological response to the pandemic, including impact on healthcare, business and the economy. Methods Epidemiological, business and economic data were extracted from official government sources covering the period 31st January to 13th August 2020; healthcare system data up to end of June 2019. Results UK-wide COVID-19 cases and deaths were 313,798 and 46,706 respectively (472 cases and 70 deaths per 100,000 population) by 12th August. There were regional variations in England, with London and North West (756 and 666 cases per 100,000 population respectively) disproportionately affected compared with other regions. As of 11th August, 13,618,470 tests had been conducted in the UK. Increased risk of mortality was associated with age (≥60 years), gender (male) and BAME groups. Since onset of the pandemic, emergency department attendance, primary care utilisation and cancer referrals and inpatient/outpatient referrals have declined; emergency ambulance and NHS111 calls increased. Business sectors most impacted are the arts, entertainment and recreation, followed by accommodation and food services. Government interventions aimed at curtailing the business and economic impact have been implemented, but applications for state benefits have increased. Conclusions The impact of COVID-19 on the UK population, health system and economy has been profound. More data are needed to implement the optimal policy and technological responses to preventing further spikes in COVID-19 cases, and to inform strategic planning to manage future pandemics

Prenatal and Perinatal Risk Factors for Autism at National Children’s Hospital

Background: Autism, or autism spectrum disorder, refers to a broad conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication. Objectives: To determine the demographic profile of patients diagnosed with ASD, determine the significant prenatal and perinatal risk factors associated with ASD. Results: A total of 116 subjects were included in the study with 58 cases and 58 controls. They belong to the age ranging from 4 to 16 years old. Every case had a confirmed diagnosis of autism at NCH. There was a significant association noted between neonatal jaundice, nulliparity (OR=2.38; 95% CI, 0.85-6.8) and family history of autism (OR=5.30; 95% CI, 1.29-25.1) with ASD. Exposure to x-ray, medical problems, medicine intake and maternal complications during pregnancy were not significantly associated with ASD with OR 0.74; 95% CI, (0.12-4.15), OR 1.00; 95% CI (0.38-2.61), OR1.49; 95% CI, (0.63-3.53), and OR 1.27; 95% CI, (0.28-6.05), respectively. Conclusion: The current study indicates that the only significant predictor of ASD is a family history of autism. However, neonatal jaundice, maternal age of >40 years old, smoking during pregnancy and nulliparity showed a trend towards being risk factors for ASD. None of the other prenatal and perinatal characteristics significantly predicts ASD

Eliciting willingness-to-pay to prevent hospital medication administration errors in the UK: a contingent valuation survey.

Medication errors are common in hospitals. These errors can result in adverse drug events (ADEs), which can reduce the health and well-being of patients', and their relatives and caregivers. Interventions have been developed to reduce medication errors, including those that occur at the administration stage. OBJECTIVE: We aimed to elicit willingness-to-pay (WTP) values to prevent hospital medication administration errors. DESIGN AND SETTING: An online, contingent valuation (CV) survey was conducted, using the random card-sort elicitation method, to elicit WTP to prevent medication errors. PARTICIPANTS: A representative sample of the UK public. METHODS: Seven medication error scenarios, varying in the potential for harm and the severity of harm, were valued. Scenarios were developed with input from: clinical experts, focus groups with members of the public and piloting. Mean and median WTP values were calculated, excluding protest responses or those that failed a logic test. A two-part model (logit, generalised linear model) regression analysis was conducted to explore predictive characteristics of WTP. RESULTS: Responses were collected from 1001 individuals. The proportion of respondents willing to pay to prevent a medication error increased as the severity of the ADE increased and was highest for scenarios that described actual harm occurring. Mean WTP across the scenarios ranged from £45 (95% CI £36 to £54) to £278 (95% CI £200 to £355). Several factors influenced both the value and likelihood of WTP, such as: income, known experience of medication errors, sex, field of work, marriage status, education level and employment status. Predictors of WTP were not, however, consistent across scenarios. CONCLUSIONS: This CV study highlights how the UK public value preventing medication errors. The findings from this study could be used to carry out a cost-benefit analysis which could inform implementation decisions on the use of technology to reduce medication administration errors in UK hospitals

Cost-effectiveness of an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) during emergency stroke care: Economic results from a pragmatic cluster randomized trial

Background: The Paramedic Acute Stroke Treatment Assessment (PASTA) trial evaluated an enhanced emergency care pathway which aimed to facilitate thrombolysis in hospital. A pre-planned health economic evaluation was included. The main results showed no statistical evidence of a difference in either thrombolysis volume (primary outcome) or 90-day dependency. However, counter-intuitive findings were observed with the intervention group showing fewer thrombolysis treatments but less dependency. Aims: Cost-effectiveness of the PASTA intervention was examined relative to Standard Care (SC). Methods: A within trial cost-utility analysis estimated mean costs and quality adjusted life years (QALYs) over 90 days’ time horizon. Cost were derived from resource utilisation data for individual trial participants. QALYs were calculated by mapping modified Rankin scale scores to EQ-5D-3L utility tariffs. A post-hoc subgroup analysis examined cost-effectiveness when trial hospitals were divided into compliant and non-compliant with recommendations for a stroke specialist thrombolysis rota. Results: The trial enrolled 1214 patients: 500 PASTA and 714 SC. There was no evidence of a QALY difference between groups [0·007 (95%CI -0·003 to 0·018)] but costs were lower in the PASTA group [-£1473 (95%CI: - £2736 to -£219)]. There was over 97.5% chance that the PASTA pathway would be considered cost-effective. There was no evidence of a difference in costs at seven thrombolysis rota compliant hospitals but costs at eight non-complaint hospitals costs were lower in PASTA with more dominant cost-effectiveness. Conclusions: Analyses indicate that the PASTA pathway may be considered cost-effective, particularly if deployed in areas where stroke specialist availability is limited. Trial Registration: ISRCTN12418919 www.isrctn.com/ISRCTN1241891