Objective: To evaluate the costs and outcomes associated with different sequences of oral anti-mu... more Objective: To evaluate the costs and outcomes associated with different sequences of oral anti-muscarinic agents and the selective 3-adrenoceptor agonist, mirabegron, for the treatment of overactive bladder (OAB). Methods: A Markov model with monthly cycle length and time horizon up to 3 years was designed to compare two different sequences of up to three lines of oral therapy for OAB. Patients who discontinued one oral medication could switch to another oral medication or could discontinue treatment. Patients whose symptoms were not controlled were considered for botulinum toxin or sacral nerve stimulation. Outcomes were measured by (a) number of patients with controlled symptoms (no incontinence episodes and58 micturitions per 24 h); (b) patients with no incontinence episodes per 24 hours; and (c) patients with 58 micturitions per 24 h. Results: Including a third-line oral medication before considering other treatment options improved all patient outcomes, irrespective of the specific drugs used. A three-line sequence including two generic (oxybutynin first line and tolterodine extended-release second line) and one branded drug (solifenacin 5 mg third line) resulted in inferior patient outcomes at costs similar to a sequence of branded drugs (mirabegron first line, solifenacin 5 mg second line, solifenacin 10 mg third line): controlled patients (generic 29.6/1000 vs branded 38.7/1000); patients with no incontinence episodes (103.6/1000 vs 123.7/1000); patients with58 micturitions (228.7/1000 vs 262.1/1000). Annual treatment costs per patient were similar (generic £1299 vs branded £1385). Conclusions: In the treatment of OAB, low-cost generic treatments are not necessarily more cost-effective than branded drugs, primarily because a better efficacy and tolerability balance improves both symptom control and persistence.
Study Design. Cost-effectiveness analysis Objective. To evaluate the cost-effectiveness of intrad... more Study Design. Cost-effectiveness analysis Objective. To evaluate the cost-effectiveness of intradiscal electrothermal therapy (IDET) relative to circumferential lumbar fusion with femoral ring allograft (FRA) in UK. Summary of Background Data. Circumferential lumbar fusion is an established treatment for discogenic low back pain. However, IDET could be a cost-effective treatment alternative as it can be carried out as a day case. Methods. Patient-level data were available for patients with discogenic low back pain treated with FRA (n=37) in a randomized trial of FRA vs titanium cage, and for patients recruited to a separate study evaluating the use of IDET (n=85). Both studies were carried out at a single institution in the UK. Patients were followed-up for 24 months, with data collected on low back disability (Oswestry Disability Index), back and leg pain (visual analogue scale), quality of life (SF-36), radiographic evaluations, and NHS resource use. Cost-effectiveness was measured by the incremental cost per quality-adjusted life year (QALY) gained. Results. Both treatments produced statistically significant improvements in outcome at 24month follow-up. NHS costs were significantly lower with IDET due to a shorter mean procedure time (377.4 minutes vs 49.9 minutes) and length of stay (7 days vs 1.2 days). At a threshold of £20,000 per QALY, the probability that IDET is cost-effective is high. Conclusions. Both treatments led to significant improvements in patient outcomes which were sustained for at least 24 months. Costs were lower with IDET, and for appropriate patients IDET is an effective and cost-effective treatment alternative.
This paper explores the objective of increased competition and considers whether different types ... more This paper explores the objective of increased competition and considers whether different types of competition are likely to lead to desirable market outcomes. Potential sources of market failure, and hence inefficiency, are examined. The paper then considers what type and degree of regulation may be necessary if the forces of unrestrained competition cannot be expected to achieve desirable outcomes. A number of different options, ranging from minimal regulation to central pricing schedules, are then discussed. Consideration is given to whether openness in costing and/or pricing is necessary and desirable in both short and long term. The paper raises a number of practical problems which may be faced and suggests ways in which incentives can be created to mimic the characteristics of a competitive market.
Objective: To evaluate the costs and outcomes associated with different sequences of oral anti-mu... more Objective: To evaluate the costs and outcomes associated with different sequences of oral anti-muscarinic agents and the selective 3-adrenoceptor agonist, mirabegron, for the treatment of overactive bladder (OAB). Methods: A Markov model with monthly cycle length and time horizon up to 3 years was designed to compare two different sequences of up to three lines of oral therapy for OAB. Patients who discontinued one oral medication could switch to another oral medication or could discontinue treatment. Patients whose symptoms were not controlled were considered for botulinum toxin or sacral nerve stimulation. Outcomes were measured by (a) number of patients with controlled symptoms (no incontinence episodes and58 micturitions per 24 h); (b) patients with no incontinence episodes per 24 hours; and (c) patients with 58 micturitions per 24 h. Results: Including a third-line oral medication before considering other treatment options improved all patient outcomes, irrespective of the specific drugs used. A three-line sequence including two generic (oxybutynin first line and tolterodine extended-release second line) and one branded drug (solifenacin 5 mg third line) resulted in inferior patient outcomes at costs similar to a sequence of branded drugs (mirabegron first line, solifenacin 5 mg second line, solifenacin 10 mg third line): controlled patients (generic 29.6/1000 vs branded 38.7/1000); patients with no incontinence episodes (103.6/1000 vs 123.7/1000); patients with58 micturitions (228.7/1000 vs 262.1/1000). Annual treatment costs per patient were similar (generic £1299 vs branded £1385). Conclusions: In the treatment of OAB, low-cost generic treatments are not necessarily more cost-effective than branded drugs, primarily because a better efficacy and tolerability balance improves both symptom control and persistence.
To evaluate the cost-effectiveness IDET relative to circumferential lumbar fusion with femoral ri... more To evaluate the cost-effectiveness IDET relative to circumferential lumbar fusion with femoral ring allograft (FRA). Cost-effectiveness analysis Patient-level data were available for patients with discogenic low back pain treated with FRA (n=37) in a randomized trial of FRA vs. titanium cage, and for patients recruited to a separate study evaluating the use of IDET (n=85). Patients were followed-up for 24 months. Oswestry Disability Index, visual analogue scale, quality of life (SF-36), radiographic evaluations, and NHS resource use. Cost-effectiveness was measured by the incremental cost per quality-adjusted life year (QALY) gained. Both treatments produced statistically significant improvements in pain, disability and quality of life at the 24-month follow-up. Costs were significantly lower with IDET due to a shorter mean procedure time (377.4 minutes vs. 49.9 minutes) and length of stay (7 days vs. 1.2 days). The mean incremental cost of IDET was -£3,713 per patient; the mean incremental QALY gain was 0.03. At a threshold of £20,000 per QALY the probability that IDET is cost-effective is 1, and the net health benefit is 0.21 QALY per patient treated. Both treatments led to significant improvements in patient outcomes which were sustained for at least 24 months. Costs were lower with IDET, and for appropriate patients IDET is an effective and cost-effective treatment alternative. Ethics approval: Ethics committee COREC This cost-effectiveness analysis was carried out by the York Health Economics Consortium at the University of York, and was funded by Smith & Nephew. Smith & Nephew had no financial or other involvement in the collection or analysis of the data on which the CEA is based.
As universities adjust to the current financial squeeze, their room for manoeuvre is severely lim... more As universities adjust to the current financial squeeze, their room for manoeuvre is severely limited by the present academic salary structure. A more flexible system would have the advantage of separating, in the academic sheep, the meat of teaching from the wool of research, and of providing incentives for improving the quality of both.
OBJECTIVE Preeclampsia is a major obstetric disorder that can lead to severe maternal, fetal and ... more OBJECTIVE Preeclampsia is a major obstetric disorder that can lead to severe maternal, fetal and infant outcomes. In women with suspected preeclampsia, measurement of the soluble fms-like tyrosine kinase-1 (sFlt1) and placental growth factor (PlGF) ratio has been shown to have a high negative predictive value (>97%). Our aim was to estimate the value to the US healthcare system of adopting this test into clinical practice. STUDY DESIGN An economic model was developed for the evaluation of suspected preeclampsia from a US payer perspective using data from a US observational study of 459 women evaluated between 23 and 34.6 weeks. Test results were not available to clinicians. The model compares two strategies for managing suspected preeclampsia: standard care versus a biomarker-informed pathway utilizing the sFlt1/PlGF ratio. RESULTS Utilization of the sFlt1/PlGF ratio test reduced the number of women admitted for suspected preeclampsia by 34-49%. Despite fewer admissions, a higher proportion of women admitted to hospital subsequently developed preeclampsia, and the proportion of women not admitted who would subsequently develop preeclampsia remained low (3.2%-6.7%). Cost savings arising from a reduction in admissions are estimated to be $1050 in the base case; varying the hospitalization cost ±25% would lead to savings in the range $771 to $1330 per patient at 2020 prices. CONCLUSION Adopting the sFlt1/PlGF ratio test as an adjunct to clinical criteria improves the assessment of risk in women presenting with suspicion of preeclampsia and has the potential to safely reduce unnecessary admissions and save costs.
To evaluate the cost-effectiveness of a soluble betaglucan-containing gel as short-term adjunct t... more To evaluate the cost-effectiveness of a soluble betaglucan-containing gel as short-term adjunct therapy in the treatment of hard-to-heal wounds in a UK community health-care setting. Methods: A comparative clinical evaluation involving consecutive patients treated for up to eight weeks with a beta-glucan-containing gel as adjunct to standard care. This was compared with consecutive patients as retrospective controls, and using the same standard care protocol from a year previously. The inclusion criteria was wounds that were slow-healing or stalled (<40% healing in four weeks). Results: A total of 300 patients took part. Complete follow-up at 24 weeks was available for 144 patients in the beta-glucan group, and 136 patients in the standard care group. At 24 weeks, the beta-glucan group had a 96% healing rate compared with 75% in the standard care group (p<0.001). The improvement in healing was associated with a reduction in the mean number of weeks of treatment per patient (7.2 and 10.7 for beta-glucan and standard care, respectively), and a reduction in the mean cost of treatment (£576 versus £685 for beta-glucan and standard care, respectively). Treatment costs included nursing time, prescription medications and dressings. In a subset of ulcer wounds (50% of the full sample), at 24 weeks the beta-glucan group had a 92% healing rate compared with 46% in the standard care group (p<0.001). Mean weeks of treatment were 10.4 versus 17.6, leading to a reduction in treatment cost of £388 per patient (£1227 versus £839) over 24 weeks. Conclusion: The results of this evaluation suggest that short-term use of the beta-glucan gel as an adjunct to standard care on slowhealing wounds can shorten healing times and reduce NHS costs. Declaration of interest: SH works for a UK primary care healthcare provider. SH, FE and JP provide consulting services to pharmaceutical and medical device manufacturers, including but not limited to, Biotec Beta Glucans A/S.
What's known on the subject? and What does the study add? • UK clinical guidelines for treating m... more What's known on the subject? and What does the study add? • UK clinical guidelines for treating male patients with moderate to severe LUTS associated with BPH recommend treatment with an alpha-blocker (such as tamsulosin) in cases where conservative management options have not been successful or are not appropriate. An alpha-blocker plus 5-alpha-reductase inhibitor (such as dutasteride) is recommended for those patients with moderate to severe symptoms and prostate volume >30 mL. • The present study evaluates the cost-effectiveness of a new, single-dose combination of tamsulosin and dutasteride (Combodart®) from the perspective of the UK National Health Service. The results show that the combination therapy has a high probability of being cost-effective compared with either monotherapy, and compared with the two therapies taken separately. The probability of the combination therapy being cost-effective at an incremental cost-effectiveness ratio threshold in the range £25 000-£30 000 per quality-adjusted life year is 78-88%. Objective • To estimate the long-term cost-effectiveness of single-dose dutasteride/tamsulosin combination therapy as a first-line treatment for benign prostatic hyperplasia (BPH) from the perspective of the UK National Health Service (NHS).
This article has two purposes. First, the bounds of the neutrality theorem for the private provis... more This article has two purposes. First, the bounds of the neutrality theorem for the private provision of public goods are more firmly established The focus is on the non-neutrality of non-Nash equilibria in which nonzero conjectures depend on the agent's own contribution. The non-neutrality of equilibria involving general externalities, nonlinear constraints, and joint products are also examined Second, it is argued that non-Nash behavior and joint products, induced by institutional design, may be behind the contribution patterns reported by some researchers who investigate charities.
This article discusses the costs of chronic wound management and the impact on patients and the h... more This article discusses the costs of chronic wound management and the impact on patients and the healthcare system.
Whilst significant advances have been made in persuading clinical researchers of the value of con... more Whilst significant advances have been made in persuading clinical researchers of the value of conducting economic evaluation alongside clinical trials, a number of problems remain. The most fundamental is the fact that economic principles are almost entirely ignored in the traditional approach to trial design. For example, in the selection of an optimal sample size no consideration is given to the marginal costs or benefits of sample information. In the traditional approach this can lead to either unbounded or arbitrary sample sizes. This paper presents a decision-analytic approach to trial design which takes explicit account of the costs of sampling, the benefits of sample information and the decision rules of cost-effectiveness analysis. It also provides a consistent framework for setting priorities in research funding and establishes a set of screens (or hurdles) to evaluate the potential cost-effectiveness of research proposals. The framework permits research priority setting based explicitly on the budget constraint faced by clinical practitioners and on the information available prior to prospective research. It demonstrates the link between the value of clinical research and the budgetary restrictions on service provision, and it provides practical tools to establish the optimal allocation of resources between areas of clinical research or between service provision and research.
This paper presents the results of research carried out within a broader study of the economics o... more This paper presents the results of research carried out within a broader study of the economics of charitable activity in conjunction with Mr. A.
The 1985/86 Survey of Personal Incomes is used to estimate the impact of tax deductibility on giv... more The 1985/86 Survey of Personal Incomes is used to estimate the impact of tax deductibility on giving by covenant. Estimates are based on two models: a generalized Tobit model, and Reece and Zieschang's (1985) model that allows for a nonlinear budget constraint. The results suggest that the latter is not appropriate for the U.K. tax system. In the Tobit models, the income effects on participation and expenditure are well determined and similar to those in previous work for the United Kingdom and in many U.S. studies. There is no robust evidence of a tax-price effect on participation or expenditure. Copyright 1991 by Royal Economic Society.
The objective of this study is to estimate the cost of wound care in a local population of approx... more The objective of this study is to estimate the cost of wound care in a local population of approximately 590 000 using results from a wound care audit carried out in Hull and the East Riding of Yorkshire as a basis. Full results of the audit will be published separately. An audit in June 2005 provided information on patients with wounds and on their treatment. This was combined with representative National Health Service unit costs to produce an estimate of the total cost of wound care in 2005–2006. In all, 1644 patients had a total of 2300 wounds (1·44 per patient). Most (74·1%) were treated in the community by district nurses, 21·2% were treated in hospital and 4·8% were treated in residential or hospice care. More than one in four hospital inpatients (26·8%) had a wound. Median duration was 6–12 weeks. Twenty‐four per cent had their wound for 6 months or more, and almost 16% of patients had remained unhealed for a year or longer. One in eight wounds (12·8%) were reported as showing signs of infection. The estimated cost of wound care in 2005–2006 was £15 million to £18 million (£2·5 million to £3·1 million per 100 000 population). Caring for patients with wounds required the equivalent of 88·5 full‐time nurses and up to 87 hospital beds. Wounds are a significant source of cost to patients as well as the health care system. The most important determinant of cost appears to be wound complications which require hospitalisation or which delay hospital discharge. Reducing costs requires a systematic focus on effective and timely diagnosis, on ensuring treatment is appropriate to the cause and condition of the wound and on active measures to prevent complications and wound‐related hospitalisation. These results should be generalisable to other similar populations in the UK and elsewhere.
Estimates of survival and costs are identical for cisplatinpaclitaxel and cisplatin-gemcitabin. T... more Estimates of survival and costs are identical for cisplatinpaclitaxel and cisplatin-gemcitabin. There was a higher incidence of severe toxicities with cisplatin-gemcitabin, but differences in QoL are still to be determined. Gemcitabin-paclitaxel is a dominated option with higher costs and non-superior survival.
Objective: To evaluate the costs and outcomes associated with different sequences of oral anti-mu... more Objective: To evaluate the costs and outcomes associated with different sequences of oral anti-muscarinic agents and the selective 3-adrenoceptor agonist, mirabegron, for the treatment of overactive bladder (OAB). Methods: A Markov model with monthly cycle length and time horizon up to 3 years was designed to compare two different sequences of up to three lines of oral therapy for OAB. Patients who discontinued one oral medication could switch to another oral medication or could discontinue treatment. Patients whose symptoms were not controlled were considered for botulinum toxin or sacral nerve stimulation. Outcomes were measured by (a) number of patients with controlled symptoms (no incontinence episodes and58 micturitions per 24 h); (b) patients with no incontinence episodes per 24 hours; and (c) patients with 58 micturitions per 24 h. Results: Including a third-line oral medication before considering other treatment options improved all patient outcomes, irrespective of the specific drugs used. A three-line sequence including two generic (oxybutynin first line and tolterodine extended-release second line) and one branded drug (solifenacin 5 mg third line) resulted in inferior patient outcomes at costs similar to a sequence of branded drugs (mirabegron first line, solifenacin 5 mg second line, solifenacin 10 mg third line): controlled patients (generic 29.6/1000 vs branded 38.7/1000); patients with no incontinence episodes (103.6/1000 vs 123.7/1000); patients with58 micturitions (228.7/1000 vs 262.1/1000). Annual treatment costs per patient were similar (generic £1299 vs branded £1385). Conclusions: In the treatment of OAB, low-cost generic treatments are not necessarily more cost-effective than branded drugs, primarily because a better efficacy and tolerability balance improves both symptom control and persistence.
Study Design. Cost-effectiveness analysis Objective. To evaluate the cost-effectiveness of intrad... more Study Design. Cost-effectiveness analysis Objective. To evaluate the cost-effectiveness of intradiscal electrothermal therapy (IDET) relative to circumferential lumbar fusion with femoral ring allograft (FRA) in UK. Summary of Background Data. Circumferential lumbar fusion is an established treatment for discogenic low back pain. However, IDET could be a cost-effective treatment alternative as it can be carried out as a day case. Methods. Patient-level data were available for patients with discogenic low back pain treated with FRA (n=37) in a randomized trial of FRA vs titanium cage, and for patients recruited to a separate study evaluating the use of IDET (n=85). Both studies were carried out at a single institution in the UK. Patients were followed-up for 24 months, with data collected on low back disability (Oswestry Disability Index), back and leg pain (visual analogue scale), quality of life (SF-36), radiographic evaluations, and NHS resource use. Cost-effectiveness was measured by the incremental cost per quality-adjusted life year (QALY) gained. Results. Both treatments produced statistically significant improvements in outcome at 24month follow-up. NHS costs were significantly lower with IDET due to a shorter mean procedure time (377.4 minutes vs 49.9 minutes) and length of stay (7 days vs 1.2 days). At a threshold of £20,000 per QALY, the probability that IDET is cost-effective is high. Conclusions. Both treatments led to significant improvements in patient outcomes which were sustained for at least 24 months. Costs were lower with IDET, and for appropriate patients IDET is an effective and cost-effective treatment alternative.
This paper explores the objective of increased competition and considers whether different types ... more This paper explores the objective of increased competition and considers whether different types of competition are likely to lead to desirable market outcomes. Potential sources of market failure, and hence inefficiency, are examined. The paper then considers what type and degree of regulation may be necessary if the forces of unrestrained competition cannot be expected to achieve desirable outcomes. A number of different options, ranging from minimal regulation to central pricing schedules, are then discussed. Consideration is given to whether openness in costing and/or pricing is necessary and desirable in both short and long term. The paper raises a number of practical problems which may be faced and suggests ways in which incentives can be created to mimic the characteristics of a competitive market.
Objective: To evaluate the costs and outcomes associated with different sequences of oral anti-mu... more Objective: To evaluate the costs and outcomes associated with different sequences of oral anti-muscarinic agents and the selective 3-adrenoceptor agonist, mirabegron, for the treatment of overactive bladder (OAB). Methods: A Markov model with monthly cycle length and time horizon up to 3 years was designed to compare two different sequences of up to three lines of oral therapy for OAB. Patients who discontinued one oral medication could switch to another oral medication or could discontinue treatment. Patients whose symptoms were not controlled were considered for botulinum toxin or sacral nerve stimulation. Outcomes were measured by (a) number of patients with controlled symptoms (no incontinence episodes and58 micturitions per 24 h); (b) patients with no incontinence episodes per 24 hours; and (c) patients with 58 micturitions per 24 h. Results: Including a third-line oral medication before considering other treatment options improved all patient outcomes, irrespective of the specific drugs used. A three-line sequence including two generic (oxybutynin first line and tolterodine extended-release second line) and one branded drug (solifenacin 5 mg third line) resulted in inferior patient outcomes at costs similar to a sequence of branded drugs (mirabegron first line, solifenacin 5 mg second line, solifenacin 10 mg third line): controlled patients (generic 29.6/1000 vs branded 38.7/1000); patients with no incontinence episodes (103.6/1000 vs 123.7/1000); patients with58 micturitions (228.7/1000 vs 262.1/1000). Annual treatment costs per patient were similar (generic £1299 vs branded £1385). Conclusions: In the treatment of OAB, low-cost generic treatments are not necessarily more cost-effective than branded drugs, primarily because a better efficacy and tolerability balance improves both symptom control and persistence.
To evaluate the cost-effectiveness IDET relative to circumferential lumbar fusion with femoral ri... more To evaluate the cost-effectiveness IDET relative to circumferential lumbar fusion with femoral ring allograft (FRA). Cost-effectiveness analysis Patient-level data were available for patients with discogenic low back pain treated with FRA (n=37) in a randomized trial of FRA vs. titanium cage, and for patients recruited to a separate study evaluating the use of IDET (n=85). Patients were followed-up for 24 months. Oswestry Disability Index, visual analogue scale, quality of life (SF-36), radiographic evaluations, and NHS resource use. Cost-effectiveness was measured by the incremental cost per quality-adjusted life year (QALY) gained. Both treatments produced statistically significant improvements in pain, disability and quality of life at the 24-month follow-up. Costs were significantly lower with IDET due to a shorter mean procedure time (377.4 minutes vs. 49.9 minutes) and length of stay (7 days vs. 1.2 days). The mean incremental cost of IDET was -£3,713 per patient; the mean incremental QALY gain was 0.03. At a threshold of £20,000 per QALY the probability that IDET is cost-effective is 1, and the net health benefit is 0.21 QALY per patient treated. Both treatments led to significant improvements in patient outcomes which were sustained for at least 24 months. Costs were lower with IDET, and for appropriate patients IDET is an effective and cost-effective treatment alternative. Ethics approval: Ethics committee COREC This cost-effectiveness analysis was carried out by the York Health Economics Consortium at the University of York, and was funded by Smith & Nephew. Smith & Nephew had no financial or other involvement in the collection or analysis of the data on which the CEA is based.
As universities adjust to the current financial squeeze, their room for manoeuvre is severely lim... more As universities adjust to the current financial squeeze, their room for manoeuvre is severely limited by the present academic salary structure. A more flexible system would have the advantage of separating, in the academic sheep, the meat of teaching from the wool of research, and of providing incentives for improving the quality of both.
OBJECTIVE Preeclampsia is a major obstetric disorder that can lead to severe maternal, fetal and ... more OBJECTIVE Preeclampsia is a major obstetric disorder that can lead to severe maternal, fetal and infant outcomes. In women with suspected preeclampsia, measurement of the soluble fms-like tyrosine kinase-1 (sFlt1) and placental growth factor (PlGF) ratio has been shown to have a high negative predictive value (>97%). Our aim was to estimate the value to the US healthcare system of adopting this test into clinical practice. STUDY DESIGN An economic model was developed for the evaluation of suspected preeclampsia from a US payer perspective using data from a US observational study of 459 women evaluated between 23 and 34.6 weeks. Test results were not available to clinicians. The model compares two strategies for managing suspected preeclampsia: standard care versus a biomarker-informed pathway utilizing the sFlt1/PlGF ratio. RESULTS Utilization of the sFlt1/PlGF ratio test reduced the number of women admitted for suspected preeclampsia by 34-49%. Despite fewer admissions, a higher proportion of women admitted to hospital subsequently developed preeclampsia, and the proportion of women not admitted who would subsequently develop preeclampsia remained low (3.2%-6.7%). Cost savings arising from a reduction in admissions are estimated to be $1050 in the base case; varying the hospitalization cost ±25% would lead to savings in the range $771 to $1330 per patient at 2020 prices. CONCLUSION Adopting the sFlt1/PlGF ratio test as an adjunct to clinical criteria improves the assessment of risk in women presenting with suspicion of preeclampsia and has the potential to safely reduce unnecessary admissions and save costs.
To evaluate the cost-effectiveness of a soluble betaglucan-containing gel as short-term adjunct t... more To evaluate the cost-effectiveness of a soluble betaglucan-containing gel as short-term adjunct therapy in the treatment of hard-to-heal wounds in a UK community health-care setting. Methods: A comparative clinical evaluation involving consecutive patients treated for up to eight weeks with a beta-glucan-containing gel as adjunct to standard care. This was compared with consecutive patients as retrospective controls, and using the same standard care protocol from a year previously. The inclusion criteria was wounds that were slow-healing or stalled (<40% healing in four weeks). Results: A total of 300 patients took part. Complete follow-up at 24 weeks was available for 144 patients in the beta-glucan group, and 136 patients in the standard care group. At 24 weeks, the beta-glucan group had a 96% healing rate compared with 75% in the standard care group (p<0.001). The improvement in healing was associated with a reduction in the mean number of weeks of treatment per patient (7.2 and 10.7 for beta-glucan and standard care, respectively), and a reduction in the mean cost of treatment (£576 versus £685 for beta-glucan and standard care, respectively). Treatment costs included nursing time, prescription medications and dressings. In a subset of ulcer wounds (50% of the full sample), at 24 weeks the beta-glucan group had a 92% healing rate compared with 46% in the standard care group (p<0.001). Mean weeks of treatment were 10.4 versus 17.6, leading to a reduction in treatment cost of £388 per patient (£1227 versus £839) over 24 weeks. Conclusion: The results of this evaluation suggest that short-term use of the beta-glucan gel as an adjunct to standard care on slowhealing wounds can shorten healing times and reduce NHS costs. Declaration of interest: SH works for a UK primary care healthcare provider. SH, FE and JP provide consulting services to pharmaceutical and medical device manufacturers, including but not limited to, Biotec Beta Glucans A/S.
What's known on the subject? and What does the study add? • UK clinical guidelines for treating m... more What's known on the subject? and What does the study add? • UK clinical guidelines for treating male patients with moderate to severe LUTS associated with BPH recommend treatment with an alpha-blocker (such as tamsulosin) in cases where conservative management options have not been successful or are not appropriate. An alpha-blocker plus 5-alpha-reductase inhibitor (such as dutasteride) is recommended for those patients with moderate to severe symptoms and prostate volume >30 mL. • The present study evaluates the cost-effectiveness of a new, single-dose combination of tamsulosin and dutasteride (Combodart®) from the perspective of the UK National Health Service. The results show that the combination therapy has a high probability of being cost-effective compared with either monotherapy, and compared with the two therapies taken separately. The probability of the combination therapy being cost-effective at an incremental cost-effectiveness ratio threshold in the range £25 000-£30 000 per quality-adjusted life year is 78-88%. Objective • To estimate the long-term cost-effectiveness of single-dose dutasteride/tamsulosin combination therapy as a first-line treatment for benign prostatic hyperplasia (BPH) from the perspective of the UK National Health Service (NHS).
This article has two purposes. First, the bounds of the neutrality theorem for the private provis... more This article has two purposes. First, the bounds of the neutrality theorem for the private provision of public goods are more firmly established The focus is on the non-neutrality of non-Nash equilibria in which nonzero conjectures depend on the agent's own contribution. The non-neutrality of equilibria involving general externalities, nonlinear constraints, and joint products are also examined Second, it is argued that non-Nash behavior and joint products, induced by institutional design, may be behind the contribution patterns reported by some researchers who investigate charities.
This article discusses the costs of chronic wound management and the impact on patients and the h... more This article discusses the costs of chronic wound management and the impact on patients and the healthcare system.
Whilst significant advances have been made in persuading clinical researchers of the value of con... more Whilst significant advances have been made in persuading clinical researchers of the value of conducting economic evaluation alongside clinical trials, a number of problems remain. The most fundamental is the fact that economic principles are almost entirely ignored in the traditional approach to trial design. For example, in the selection of an optimal sample size no consideration is given to the marginal costs or benefits of sample information. In the traditional approach this can lead to either unbounded or arbitrary sample sizes. This paper presents a decision-analytic approach to trial design which takes explicit account of the costs of sampling, the benefits of sample information and the decision rules of cost-effectiveness analysis. It also provides a consistent framework for setting priorities in research funding and establishes a set of screens (or hurdles) to evaluate the potential cost-effectiveness of research proposals. The framework permits research priority setting based explicitly on the budget constraint faced by clinical practitioners and on the information available prior to prospective research. It demonstrates the link between the value of clinical research and the budgetary restrictions on service provision, and it provides practical tools to establish the optimal allocation of resources between areas of clinical research or between service provision and research.
This paper presents the results of research carried out within a broader study of the economics o... more This paper presents the results of research carried out within a broader study of the economics of charitable activity in conjunction with Mr. A.
The 1985/86 Survey of Personal Incomes is used to estimate the impact of tax deductibility on giv... more The 1985/86 Survey of Personal Incomes is used to estimate the impact of tax deductibility on giving by covenant. Estimates are based on two models: a generalized Tobit model, and Reece and Zieschang's (1985) model that allows for a nonlinear budget constraint. The results suggest that the latter is not appropriate for the U.K. tax system. In the Tobit models, the income effects on participation and expenditure are well determined and similar to those in previous work for the United Kingdom and in many U.S. studies. There is no robust evidence of a tax-price effect on participation or expenditure. Copyright 1991 by Royal Economic Society.
The objective of this study is to estimate the cost of wound care in a local population of approx... more The objective of this study is to estimate the cost of wound care in a local population of approximately 590 000 using results from a wound care audit carried out in Hull and the East Riding of Yorkshire as a basis. Full results of the audit will be published separately. An audit in June 2005 provided information on patients with wounds and on their treatment. This was combined with representative National Health Service unit costs to produce an estimate of the total cost of wound care in 2005–2006. In all, 1644 patients had a total of 2300 wounds (1·44 per patient). Most (74·1%) were treated in the community by district nurses, 21·2% were treated in hospital and 4·8% were treated in residential or hospice care. More than one in four hospital inpatients (26·8%) had a wound. Median duration was 6–12 weeks. Twenty‐four per cent had their wound for 6 months or more, and almost 16% of patients had remained unhealed for a year or longer. One in eight wounds (12·8%) were reported as showing signs of infection. The estimated cost of wound care in 2005–2006 was £15 million to £18 million (£2·5 million to £3·1 million per 100 000 population). Caring for patients with wounds required the equivalent of 88·5 full‐time nurses and up to 87 hospital beds. Wounds are a significant source of cost to patients as well as the health care system. The most important determinant of cost appears to be wound complications which require hospitalisation or which delay hospital discharge. Reducing costs requires a systematic focus on effective and timely diagnosis, on ensuring treatment is appropriate to the cause and condition of the wound and on active measures to prevent complications and wound‐related hospitalisation. These results should be generalisable to other similar populations in the UK and elsewhere.
Estimates of survival and costs are identical for cisplatinpaclitaxel and cisplatin-gemcitabin. T... more Estimates of survival and costs are identical for cisplatinpaclitaxel and cisplatin-gemcitabin. There was a higher incidence of severe toxicities with cisplatin-gemcitabin, but differences in QoL are still to be determined. Gemcitabin-paclitaxel is a dominated option with higher costs and non-superior survival.
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Papers by John Posnett