Managing orthopaedic waiting lists

Waiting lists are often assumed to be natural products of the demand and supply interplay in the hospital treatment ‘market.’ However, they can frequently be highly imperfect markets due to the organisational arrangements which surround them. In fact, when organised poorly, the arrangements for matching waiting list patients with available hospital resources actually contribute to waiting times. The author has spent much time in several orthopaedic departments in one Region and has observed the different ways in which waiting lists are organised. Experience of this has led to the drawing up of a short-list of ‘good practices’ which may ensure that both hospital and patient resources are used as effectively as possible. In addition to these practical measures, the precise definition of a waiting list is also explored which has implications for those seeking to illuminate and interpret their own problems. It is shown how clinicians can ‘vire’ patients between the two main types of waiting list, namely for out-patient appointments and in-patient treatment and the relative advantages of such strategies. Finally, the paper looks at the current information that most orthopaedic departments holds about waiting list patients and shoes how this is inadequate both for patient administration and for planning purposes.

Appraising workload and the scope for change in orthopaedics

This paper describes a method of appraising general workload in any Orthopaedic Department and can be used by Surgeons themselves as well as management to assess performance. During the period 1983-1986, the Author undertook research in three different Orthopaedic Departments in one Region. In each department a standard initial phase of work was carried out to assess the potential for improvements in the way resources were used. This initial approach became a useful standard method of appraising the main areas of workload and their inter-relationships. The approach described uses official hospital data supplemented as far as possible by data collection locally. As well as helping the Author to identify specific areas of investigation amenable to further economic evaluation (e.g. See CHE Discussion Paper 14) a general picture of a ‘typical’ orthopaedic department was built up during this process. Relationships between one part of the Orthopaedic ‘system’ and another were carefully enumerated at hospital level and knowledge of these can also help other departments engage in the process of ‘self-audit’. Some departments moreover may which to refine the data locally and therefore the method of calculation and the sources of data are provided in the appendices. The second part of this paper deals with the implications for workload of different organisational arrangements. For example, what impact could the provision of an overnight stay ward have on the throughput of in-patient beds? Is it better to separate cold and trauma orthopaedic beds formally or leave this flexible? Using the model of an orthopaedic department described it is possible for those influencing the pattern of Orthopaedic care at a district level to anticipate the effects of policy changes before actual implementation. Specific changes of policy, however, require further analysis to assess the effects on costs and outcome; these can be provided with the help of a health economist.orthopaedics

A cost-benefit analysis of open access to physiotherapy for GPs

A pilot scheme for general practitioner open-access to physiotherapy began with the Tormorden practice in June 1985. This pilot scheme was studied by the authors for a thirteen-month period between August 1985 and September 1986 to establish the main cost-benefit implications of providing such a service in this area. The study was designed in consultation with senior officers of the Calderdale Health Authority and involved the Hebden Bridge group practice as a means of comparing a similar practice with a similar population but without an open access facility (control group). Patients in six pre-selected condition groups were chosen as potential beneficiaries of this pilot service and in both practices the progress of these groups of patients were followed irrespective of whether they received physiotherapy via open-access or a consultant referral or not at all (in the case of some control group patients). The main aims of the study were: (i) to assess the impact of open-access on hospital and general practitioner workload and (ii) to quantify the costs and benefits of such a scheme affecting patients, the physiotherapy service and (to a limited extent) on general practitioners. The full conclusions of this study are to be found in Section 6. However, the following are the major findings of this report: 1) The additional (marginal) cost to the physiotherapy department of providing open access for selected patients from one practice was around £3,298 per annum. 2) The service was used responsibly by referring GPs who, in their opinion, found it to be a very useful treatment option. 3) The availability of the open-access service reduced the number of consultant referrals (both urgent and non-urgent), especially those who would have ultimately been seen in the physiotherapy department. 4) The availability of the open-access service generated a demand for physiotherapy services which, under normal circumstances, would have gone unmet and been managed by the patients’ general practitioner. 5) Open-access physiotherapy produced improvements in the patients’ condition (as assessed by both patients and physiotherapists) although no great difference in benefit could be found when compared with physiotherapy obtained by consultant referral (except Group 2) or no physiotherapy at all. 6) Open-access patients used significantly less physiotherapy time and sessions than their consultant counterparts. This reduced the average treatment costs per case from £42 to £25 per case (revenue costs only). 7) The availability of open-access did not reduce the general practitioners’ workload as measured in terms of the number of patient consultations. 8) Open-access patients waited significantly less time to obtain physiotherapy than those patients referred to a consultant. This was reduced from 124 days to 22 days in the study group. This report is a summarised version of a fill report prepared for the Calderdale Health Authority in 1987. Copies of the full report are available from the Authors on request.physiotherapist

The economic benefit of hip replacement: a 5-year follow-up of costs and outcomes in the Exeter Primary Outcomes Study

To assess changes in quality of life and costs of patients undergoing primary total hip replacement using the Exeter prosthesis compared with a hypothetical 'no surgery' group

Adrenal lesions found incidentally: how to improve clinical and cost-effectiveness

Introduction Adrenal incidentalomas are lesions that are incidentally identified while scanning for other conditions. While most are benign and hormonally non-functional, around 20% are malignant and/or hormonally active, requiring prompt intervention. Malignant lesions can be aggressive and life-threatening, while hormonally active tumours cause various endocrine disorders, with significant morbidity and mortality. Despite this, management of patients with adrenal incidentalomas is variable, with no robust evidence base. This project aimed to establish more effective and timely management of these patients. Methods We developed a web-based, electronic Adrenal Incidentaloma Management System (eAIMS), which incorporated the evidence-based and National Health Service–aligned 2016 European guidelines. The system captures key clinical, biochemical and radiological information necessary for adrenal incidentaloma patient management and generates a pre-populated outcome letter, saving clinical and administrative time while ensuring timely management plans with enhanced safety. Furthermore, we developed a prioritisation strategy, with members of the multidisciplinary team, which prioritised high-risk individuals for detailed discussion and management. Patient focus groups informed process-mapping and multidisciplinary team process re-design and patient information leaflet development. The project was partnered by University Hospital of South Manchester to maximise generalisability. Results Implementation of eAIMS, along with improvements in the prioritisation strategy, resulted in a 49% reduction in staff hands-on time, as well as a 78% reduction in the time from adrenal incidentaloma identification to multidisciplinary team decision. A health economic analysis identified a 28% reduction in costs. Conclusions The system’s in-built data validation and the automatic generation of the multidisciplinary team outcome letter improved patient safety through a reduction in transcription errors. We are currently developing the next stage of the programme to proactively identify all new adrenal incidentaloma cases

Feasibility study of a randomised controlled trial to investigate the treatment of sarcoidosis-associated fatigue with methylphenidate (FaST-MP): a study protocol

Introduction: Fatigue is a frequent and troublesome manifestation of chronic sarcoidosis. This symptom can be debilitating and difficult to treat, with poor response to the treatment. Symptomatic management with neurostimulants, such as methylphenidate, is a possible treatment option. The use of such treatment strategies is not without precedent and has been trialled in cancer-related fatigue. Their use in sarcoidosis requires further evaluation before it can be recommended for clinical practice. Methods and analysis: The Fatigue and Sarcoidosis—Treatment with Methylphenidate study is a randomised, controlled, parallel-arm and feasibility trial of methylphenidate for the treatment of sarcoidosis-associated fatigue. Patients are eligible if they have a diagnosis of sarcoidosis, significant fatigue (measured using the Fatigue Assessment Scale) and have stable disease. Up to 30 participants will be randomly assigned to either methylphenidate (20 mg two times per day) or identical placebo in a 3:2 ratio for 24 weeks. The primary objective is to collect data determining the feasibility of a future study powered to determine the clinical efficacy of methylphenidate for sarcoidosis-associated fatigue. The trial is presently open and will continue until July 2018. Ethics and dissemination: Ethical approval for the study was granted by the Cambridge Central Research Ethics Committee on 21 June 2016 (reference 16/EE/0087) and was approved and sponsored by the Norfolk and Norwich University Hospital (reference 190280). Clinical Trial Authorisation (EudraCT number 2016-000342-60) from the Medicines and Healthcare products Regulatory Agency (MHRA) was granted on 19 April 2016. Results will be presented at relevant conferences and submitted to appropriate journals following trial closure and analysis

Developing a prioritisation framework in an English Primary Care Trust.

BACKGROUND: In the English NHS, Primary Care Trusts (PCTs) are required to commission health services, to maximise the well-being of the population, subject to the available budget. There are numerous techniques employed to make decisions, some more rational and transparent than others. A weighted benefit score can be used to rank options but this does not take into account value for money from investments. METHODS: We developed a weighted benefit score framework for use in an English PCT which ranked options in order of 'cost-value' or 'cost per point of benefit'. Our method differs from existing techniques by explicitly combining cost and a composite weighted benefit score into the cost-value ratio. RESULTS: The technique proved readily workable, and was able to accommodate a wide variety of data and competing criteria. Participants felt able to assign scores to proposed services, and generate a ranked list, which provides a solid starting point for the PCT Board to discuss and make funding decisions. Limitations included potential for criteria to be neither exhaustive nor mutually exclusive and the lack of an interval property in the benefit score limiting the usefulness of a cost-value ratio. CONCLUSION: A technical approach to decision making is insufficient for making prioritisation decisions, however our technique provides a very valuable, structured and informed starting point for PCT decision making

A cost-benefit study of geriatric-orthopaedic management of patients with fractured neck of femur

Having identified woman over 65 with the condition, fractured neck of femur, as the main cause of slow throughput and low bed availability on the acute orthopaedic wards at Huddersfield, it was decided to review existing management policies towards this group of patients. After consultation with the Orthopaedic and Geriatric Specialties, it was decided that a possible means of improving throughput was to instigate a policy of joint Geriatric-Orthopaedic management for these patients. It was envisaged that this scheme might also improve the quality of care and therefore the outcome of treatment. Six orthopaedic rehabilitation beds at St. Luke's, a mainly long stay hospital, three miles from the District General Hospital (DGH) were converted into Geriatric-Orthopaedic beds. This site at the time was the main base for the district Geriatric Servicec as well as providing some Orthopaedic rehabilitation beds. A standardised format of Geriatric-Orthopaedic management was agreed between the two specialties. Patients admitted with this condition admitted during the course of the year commencing March 1984, were then randomly assigned by the research team, to either the new joint management sustem or to single speciality Orthopaedic management as before. The evaluative criteria on which the two systems were judged can be divided into two main categories, namely costs (to the Hospital sector) and benefits (to the individla patients and to the Hospital sector). Costs taken into consideration included the number of bed days utilised (as a general indicator of fixed costs) and staff input into rehabilitation, e.g. physiotherapist's, occupational therapist's, social worker's time (as indicators of variable costs). Benefit, or outcome of treatment, was measured by the availability of patients in the trial to undertake standard 'activities of daily living' tests (ADLs) at fixed intervals up to and including discharge (e.g. patients' ability to stand, dress, etc.). Outcome was also measured in terms of a therapist's prognosis and success in returning patients back to their home environments.geriatric, orthopaedic

Early economic evaluation of the digital gait analysis system for fall prevention–Preliminary analysis of the GaitSmart system

Objective: To develop an early economics evaluation (EEE) to assess the cost-effectiveness of the GS in reducing the RoF and FoF. Methods: A cost-effectiveness analysis (CEA) with a return on investment (RoI) estimation was performed. CEA used the most relevant parameters, such as increased gait speed and decreased FoF, to estimate the reduction in the RoF, the impact on health care resources used and financial implications for the National Health System in the United Kingdom. Outcomes were measured as incremental cost-effectiveness ratio per quality-adjusted life years (QALYs) gained based on the reduction of the RoF and FoF. Uncertainties around the main parameters used were evaluated by probabilistic sensitivity analysis. Results: The CEA results showed that the GS is a dominant strategy over the standard of care to improve the movements of older persons who have suffered a fall or are afraid of falling (incremental QALYs based on FoF = 0.77 and QALYs based on RoF = 1.07, cost of FoF = -£4479.57 and cost of RoF = -£2901.79). By implementing the GS, the ROI results suggest that every pound invested in the GS could result in cost savings of £1.85/patient based on the RoF reduction and £11.16/patient based on the FoF reduction. The probability of being cost saving based on the number of iterations were 79.4 percent (based on FoF) and 100 percent (based on RoF). Conclusion: The EEE supports the main hypothesis that the GS is an effective intervention to avoid falls and is potentially cost saving