Use of dermal regeneration templates in a low resource environment

Modern burn care in a sophisticated well-resourced centre in a rich country utilises an increasing number of expensive adjuncts to optimise outcomes such as dermal templates, cultured keratinocytes, biological and silver impregnated dressings. Translating the use of these into a low resource environment is not a simple matter of providing the materials free of charge and there needs to be careful consideration of both the positive and negative consequences and the impact on both an individual and a population level

Normalisation process theory and the implementation of a new glaucoma clinical pathway in hospital eye services: Perspectives of doctors, nurses and optometrists

BackgroundNormalisation process theory reports the importance of contextual integration in successfully embedding novel interventions, with recent propositions detailing the role that ‘plasticity’ of intervention components and ‘elasticity’ of an intended setting contribute. We report on the introduction of a clinical pathway assessing patient non-responsiveness to treatment for glaucoma and ocular hypertension. The aim of this study was to assess the feasibility of implementing the Cardiff Model of Glaucoma Care into hospital eye services, identifying any issues of acceptability for staff through the filter of normalisation process theory.MethodsA prospective observational study was undertaken in four hospital eye services. This incorporated detailed qualitative semi-structured interviews with staff (n = 8) to gather their perceptions on the intervention’s usefulness and practicality. In addition, observational field notes of patient and staff consultations (n = 88) were collected, as well as broader organisational observations from within the research sites (n = 52). Data collection and analysis was informed by the normalisation process theory framework.ResultsStaff reported the pathway led to beneficial knowledge on managing patient treatment, but the model was sometimes perceived as overly prescriptive. This perception varied significantly based on the composition of clinics in relation to staff experience, staff availability and pre-existing clinical structures. The most commonly recounted barrier came in contextually integrating into sites where wider administrative systems were inflexible to intervention components.ConclusionsFlexibility will be the key determinant of whether the clinical pathway can progress to wider implementation. Addressing the complexity and variation associated with practice between clinics required a remodelling of the pathway to maintain its central benefits but enhance its plasticity. Our study therefore helps to confirm propositions developed in relation to normalisation process theory, contextual integration, intervention plasticity, and setting elasticity. This enables the transferability of findings to healthcare settings other than ophthalmology, where any novel intervention is implemented

Estimating the cost impact of dressing choice in the context of a mass burns casualty event

SUMMARY. Mass casualty burn events (MCBs) require intense and complex management. Silver-infused longer use dressingsmight help optimise management of burns in an MCB setting. We developed a model estimating the impact of dressing choice inthe context of an MCB. The model was developed in Excel in collaboration with experienced emergency response clinicians. Themodel compares use of silver-infused dressings with use of traditional dressings in patients with partial thickness burns covering30% of their body. Costs were estimated from a UK perspective as a proxy for a funded emergency response team and limitedto cost of dressings, bandages, padding, analgesia and staff time. Expected patient costs and resource use were summarised overan acute 2-week intervention period and extrapolated to estimate possible time savings in a hypothetical MCB. Per patient costswere estimated at £2,002 (silver) and £1,124 (traditional) (a daily additional spend of £63). Per patient staff time was estimatedat 864 minutes (silver) and 1,200 minutes (traditional) (a daily time saving of 24 minutes). Multiplying up to a possible MCBpopulation of 20 could result in a saving equivalent to 9 staff shifts over the 2-week intervention period. The model was sensitiveto type of silver dressing, frequency of dressing change and staff costs. We found increased costs through use of silver dressingsbut time savings that might help optimise burns management in an MCB. Exploring the balance between costs and staff timemight help future MCB response preparation.Keywords: mass casualty incident, burns, silver dressing, SSD, cost mode

Liothyronine for hypothyroidism: A candidate for disinvestment or in need of further research?:A value of information analysis

OBJECTIVE: Medicines with limited evidence of effectiveness are prime candidates for disinvestment. However, investment in further research may be preferable to deimplementation, given that the absence of evidence is not evidence of absence, and research can inform formulary decisions. A case in point is liothyronine, which is sometimes prescribed to levothyroxine-treated patients who continue to experience hypothyroid symptoms. It is a putative low value medicine, associated with uncertainties in both clinical and cost-effectiveness. The aim was to assess the cost-effectiveness of liothyronine in this context, and estimate the value of conducting further research. DESIGN: Cost utility and value of information analyses. SETTING: Primary care within the National Health Service in the UK. PARTICIPANTS: Fifty-four levothyroxine-treated patients with persistent symptoms of hypothyroidism. INTERVENTIONS: Liothyronine plus levothyroxine versus levothyroxine alone. PRIMARY AND SECONDARY OUTCOME MEASURES: Incremental cost per quality-adjusted life year (QALY) gained, and the expected monetary value of sample information. RESULTS: 20/54 (37%) of patients who responded to the survey reported severe problems in carrying out usual activities of everyday living and 12/54 (22%) reported severe anxiety or depression symptoms. Mean (SD) utility was 0.53 (0.23). The differences in expected total, 10-year costs and QALYs between a treatment strategy of liothyronine/levothyroxine combination therapy, and levothyroxine alone, was £12 053 and 1.014, respectively. The incremental cost-effectiveness ratio of £11 881 per QALY gained was sensitive to the price of liothyronine. The probability of liothyronine/levothyroxine combination therapy being cost effective at a threshold of £20 000 per QALY was 0.56. The value of reducing uncertainty in the efficacy of treatment was £3.64 m per year in the UK. CONCLUSIONS: A definitive clinical trial to confirm clinical effectiveness may be preferable to immediate disinvestment, and would be justified given the value of the information gained far exceeds the cost

Cost-effectiveness of biennial screening for diabetes related retinopathy in people with type 1 and type 2 diabetes compared to annual screening

Objective: Examine the health and economic impact of extending screening intervals in people with Type 2 diabetes (T2DM) and Type 1 diabetes (T1DM) without diabetes related retinopathy (DR).Setting: Diabetic Eye Screening Wales (DESW)Study design: Retrospective observational study with cost utility analysis (CUA) and Decremental Cost Effectiveness Ratios (DCER) study.Intervention: Biennial screening versus usual care (annual screening). Inputs: Anonymised data from DESW were linked to primary care data for people with two prior screening events with no DR. Transition probabilities for progression to DR were estimated based on a subset of 26,812 and 1,232 people with T2DM and T1DM, respectively. DCER above £20,000 per QALY was considered cost-effective.Results: The base case analysis DCER results of £71,243 and £23,446 per QALY for T2DM and T1DM respectively at a 3.5% discount rate and £56,822 and £14,221 respectively when discounted at 1.5% . Diabetes management represented by the mean HbA1c was 7.5% for those with T2DM and 8.7% for T1DM.Sensitivity analysis: Extending screening to biennial based on HbA1c, being the strongest predictor of progression of DR, at three levels of HbA1c 6.5%, 8.0% and 9.5% lost one QALY saving the NHS £106,075; £58,653 and £31,626 respectively for T2DM and £94,696, £37,646 and £11,089 respectively for T1DM. In addition, extending screening to biennial based on duration of diabetes >6 years for T2DM per QALY lost, saving the NHS £54,106 and for 6-12 and >12 years for T1DM saving £83,856, £23,446 and £13,340 respectively. Conclusions: Base case and sensitivity analyses indicates biennial screening to be cost-effective for T2DM irrespective of HbA1c and duration of diabetes. However, the uncertainty around the DCER indicates that annual screening should be maintained for those with T1DM especially when the HbA1c exceeds 80 mmol/mol (9.5%) and duration of diabetes is greater than 12 years

Evaluation of the Social Services and Well-being (Wales) Act 2014 Literature Review

This document is a summary of the extensive review of the literature to inform the evaluation of the Social Services and Well-being (Wales) Act 2014 (hereafter referred to as ‘the Act’)

Wet Age Related Macular Degeneration services in the community: A pathfinder evaluation - Final Report

This report summarises our evaluation of four different pathfinder services for people with wet Age Related Macular Degeneration (wet AMD). They are provided in the community setting rather than the hospital. Based on our findings we make recommendations about the delivery and sustainability for the future of such community based services for people with wet AMD in Wales