Health equity monitoring for healthcare quality assurance.

Population-wide health equity monitoring remains isolated from mainstream healthcare quality assurance. As a result, healthcare organizations remain ill-informed about the health equity impacts of their decisions - despite becoming increasingly well-informed about quality of care for the average patient. We present a new and improved analytical approach to integrating health equity into mainstream healthcare quality assurance, illustrate how this approach has been applied in the English National Health Service, and discuss how it could be applied in other countries. We illustrate the approach using a key quality indicator that is widely used to assess how well healthcare is co-ordinated between primary, community and acute settings: emergency inpatient hospital admissions for ambulatory care sensitive chronic conditions ("potentially avoidable emergency admissions", for short). Whole-population data for 2015 on potentially avoidable emergency admissions in England were linked with neighborhood deprivation indices. Inequality within the populations served by 209 clinical commissioning groups (CCGs: care purchasing organizations with mean population 272,000) was compared against two benchmarks - national inequality and inequality within ten similar populations - using neighborhood-level models to simulate the gap in indirectly standardized admissions between most and least deprived neighborhoods. The modelled inequality gap for England was 927 potentially avoidable emergency admissions per 100,000 people, implying 263,894 excess hospitalizations associated with inequality. Against this national benchmark, 17% of CCGs had significantly worse-than-benchmark equity, and 23% significantly better. The corresponding figures were 11% and 12% respectively against the similar populations benchmark. Deprivation-related inequality in potentially avoidable emergency admissions varies substantially between English CCGs serving similar populations, beyond expected statistical variation. Administrative data on inequality in healthcare quality within similar populations served by different healthcare organizations can provide useful information for healthcare quality assurance.

Socioeconomic deprivation and the burden of head and neck cancer-Regional variations of incidence and mortality in Merseyside and Cheshire, North West, England.

OBJECTIVES: The aim of this longitudinal study was to examine the distribution of head and neck cancer (HANC) disease burden across the region comparing it to national trends. DESIGN: We undertook a retrospective study of routine data combining it with indicators of deprivation and lifestyle at small geographical areas within the 9 Local Authorities (LAs) of Merseyside and Cheshire Network (MCCN) for head and neck cancers. Data from the North West of England and England were used as comparator regions. SETTING: This research was undertaken by the Cheshire and Merseyside Public Health Collaborative, UK. PARTICIPANTS: The Merseyside and Cheshire region serves a population of 2.2 million. Routine data allowed us to identify HANC patients diagnosed with cancers coded ICD C00-C14 and C30-C32 within 3 cohorts 1998-2000, 2008-2010 and 2009-2011 for our analysis. MAIN OUTCOME MEASURES: Directly age-standardised incidence rates and directly age-standardised mortality rates in the LAs and comparator regions were measured. Lifestyle and deprivation indicators were plotted against them and measured by Pearson's correlation coefficients. RESULTS: The incidence of head and neck cancer has increased across the region from 1998-2000 to 2008-2010 with a peak incidence for Liverpool males at 35/100 000 population. Certain Middle Super Output Areas contribute disproportionately to the significant effect of incidence and mortality within LAs. Income deprivation had the strongest correlation with incidence (r = .59) and mortality (r = .53) of head and neck cancer. CONCLUSION: Our study emphasises notable geographical variations within the region which need to be addressed through public health measures.

The cost of oropharyngeal cancer in England: A retrospective hospital data analysis.

OBJECTIVES: To estimate the total costs of treating head and neck cancers, specifically oropharyngeal, laryngeal and oral cavity cancer, in secondary care facilities in England during the period 2006/2007 to 2010/2011. DESIGN: Patient records were extracted from an English hospital database to estimate the number of patients treated for oropharyngeal, laryngeal and oral cavity cancer in England. Identified resource use was linked to published United Kingdom cost estimates to quantify the reimbursement of treatment through the Payment by Results system. SETTING: Retrospective hospital data analysis. PARTICIPANTS: From the hospital data, patient records of patients treated for oropharyngeal, laryngeal and oral cavity cancer were selected. MAIN OUTCOME MEASURES: Annual total costs of treatment, stratified by inpatient and outpatient setting and by male and female patients. RESULTS: From 2006/2007 to 2010/2011, total costs of treatment across the three head and neck cancer sites were estimated to be approximately £309 million, with 90% attributable to inpatient care (bundled costs). Oropharyngeal cancer accounted for 37% of total costs. Costs and patient numbers increased over time, largely due to a rise in oropharyngeal cancer, where total costs increased from £17.21 million to £30.32 million, with over 1400 (52%) more inpatients treated in 2010/11 compared to 2006/07. CONCLUSIONS: In 4 years, the number of patients with oropharyngeal cancer receiving some form of inpatient care increased by more than half, and associated costs increased by three quarters. This reinforces the case for prevention and early detection strategies to help contain this epidemiological and economic burden.

Donor and Domestic Financing of Primary Health Care in Low Income Countries.

Abstract-This paper evaluates resource commitments to primary health care (PHC) by donors and selected governments between 1990-2011. Donor commitments to financing PHC are assessed by reclassifying OECD/CRS data on health assistance into spending on 'PHC Service Delivery' versus spending on 'Health System Strengthening'. Domestic spending on PHC is assessed using a case study approach and National Health Accounts for two major recipients of donor assistance, Ethiopia and Nigeria. Results are generally consistent with three simple hypotheses that guide the inquiry. First, though donor funding for health among LICs has mushroomed over the last decade, it remains a miniscule share of per capita spending targets prescribed by international forums to attain universal access to basic/essential PHC services. Relative to levels of domestic public spending in LICs, however, donor funding has considerably more significance as a potential lever to improve PHC efficiency. Second, as reflected in on-going debate in the literature, donor spending on broader 'health system strengthening' has not kept up with mushrooming financing of disease control programs. Third, at country level, where the 'rubber meets the road', allocative efficiency of donor and domestic spending on health is highly conditional on contextual factors, especially political will to improve financing and delivery of PHC services, and the process of managing and implementing public spending on PHC.

Pre-exercise screening and health coaching in CHD secondary prevention: a qualitative study of the patient experience.

Secondary prevention programmes can be effective in reducing morbidity and mortality from coronary heart disease (CHD). In particular, UK guidelines, including those from the Department of Health, emphasize physical activity. However, the effects of secondary prevention programmes with an exercise component are moderate and uptake is highly variable. In order to explore patients' experiences of a pre-exercise screening and health coaching programme (involving one-to-one consultations to support exercise behaviour change), semi-structured telephone interviews were undertaken with 84 CHD patients recruited from primary care. The interviews focused on patients' experiences of the intervention including referral and any recommendations for improvement. A thematic analysis of transcribed interviews showed that the majority of patients were positive about referral. However, patients also identified a number of barriers to attending and completing the programme, including a belief they were sufficiently active already, the existence of other health problems, feeling unsupported in community-based exercise classes and competing demands. Our findings highlight important issues around the choice of an appropriate point of intervention for programmes of this kind as well as the importance of appropriate patient selection, suggesting that the effectiveness of health coaching may be under-reported as a result of including patients who are not yet ready to change their behaviours.

Home pregnancy test compared to standard-of-care ultrasound dating in the assessment of pregnancy duration.

OBJECTIVE: To determine the level of agreement between the Clearblue Digital Pregnancy Test with Conception Indicator home pregnancy test and standard-of-care ultrasound in assessing pregnancy duration in a real-life, observational setting encompassing routine, clinical care. RESEARCH DESIGN AND METHODS: This was a prospective observational study of non-pregnant women seeking conception. Women collected daily urine samples from day 1 of their next menstrual cycle. If any volunteer became pregnant, daily urine samples continued to be collected for 43 days after the LH surge. Samples from day -7 to day +28 relative to the expected period (LH surge + 15 days) were tested using the home pregnancy test. This categorised any resulting pregnancies into one of three groups: 1-2 weeks, 2-3 weeks, and 3+ weeks since conception. Information from the standard UK ultrasound dating scan was also recorded by the midwife, including the expected delivery date according to ultrasound and the expected delivery date according to LMP. MAIN OUTCOME MEASURES: Full data were available from 52 pregnant women who had conceived naturally. During the study analysis, 4786 urine samples were cross-compared with 52 routine 12-week NHS ultrasound assessments and the level of agreement between home pregnancy testing and standard-of-care ultrasound in determining pregnancy duration was calculated. RESULTS: The agreement between the gestational age as calculated by the home pregnancy test result and the exact midwife-recorded gestational age using ultrasound was 82.3%. However, when a ± 5-day range was applied to the ultrasound reading (as per routine UK clinical practice), the level of agreement was 98%. CONCLUSIONS: The home pregnancy test provides a significantly high (98%) level of agreement with standard-of-care ultrasound when assessing pregnancy duration in a real-life, observational setting which closely mirrors daily clinical practice.

The production costs of anthelmintic resistance in sheep managed within a monthly preventive drench program.

To determine the impact of anthelmintic resistance on the productivity of sheep grazed on pasture in a temperate climatic zone, 14 groups each of 20 lambs were grazed on pasture on which benzimidazole-resistant parasites had been detected previously, then treated every 28 days - seven groups with a benzimidazole anthelmintic (albendazole) and seven with monepantel, a member of a new anthelmintic action family which was assumed in advance to be completely effective in removing all established worms. Faecal egg counts and larval differentiation demonstrated the presence of albendazole resistance, predominantly in Teladorsagia circumcincta but also in Trichostrongylus spp. By days 84 and 112, egg counts were significantly higher in the albendazole-treated animals than in those treated with monepantel. The presence of anthelmintic resistance resulted in a reduction in live-weight of 2.8 kg, a significant increase in breech-soiling and a significant reduction in body condition score. Fourteen animals from each treatment were necropsied at a commercial abattoir and carcase weights and standard quality parameters recorded; there was a reduction in carcase weight of 2.8 kg in the albendazole-treated animals, and a difference in the carcase grades within each group. These measurements were used to calculate that the presence of anthelmintic resistance resulted in a 14% reduction in carcase value.

Cetuximab for the treatment of recurrent and/or metastatic squamous cell carcinoma of the head and neck.

This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of cetuximab for recurrent and/or metastatic squamous cell carcinoma of the head and neck (SCCHN) based upon a review of the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submission's evidence came from a single reasonably high-quality randomised controlled trial (RCT) [EXTREME (Erbitux in First-Line Treatment of Recurrent or Metastatic Head and Neck Cancer); n = 442] comparing cetuximab plus chemotherapy (CTX) with CTX alone. Cetuximab plus CTX had significant effects compared with CTX alone on the primary outcome of overall survival (10.1 versus 7.4 months respectively) and the secondary outcomes of progression-free survival (PFS) (5.6 versus 3.3 months), best overall response to therapy (35.6% versus 19.5%), disease control rate (81.1% versus 60%) and time-to-treatment failure (4.8 versus 3.0 months), but not on duration of response (5.6 months versus 4.7 months). No safety issues with cetuximab arose beyond those already previously documented. The manufacturer developed a two-arm state-transition Markov model to evaluate the cost-effectiveness of cetuximab plus CTX versus CTX alone, using clinical data from the EXTREME trial. The ERG recalculated the base-case cost-effectiveness results taking changes in parameters and assumptions into account. Subgroup and threshold analyses were also explored. The manufacturer reported an incremental cost-effectiveness ratio (ICER) of 121,367 pounds per quality-adjusted life-year (QALY) gained and an incremental cost per life-year gained of 92,226 pounds. Univariate sensitivity analysis showed that varying the cost of day-case infusion and the utility values in the stable/response health state of the cetuximab plus CTX arm had the greatest impact on the ICER. Probabilistic sensitivity analysis illustrated that cetuximab plus CTX is unlikely to be cost-effective for patients with recurrent and/or metastatic SCCHN, even at what would usually be considered very high levels of willingness to pay for an additional QALY. With regard to the economic model the appropriateness and reliability of parametric survival projection beyond the duration of trial data could not be fully explored because of lack of information. The ERG also questioned the appropriateness of economic modelling in this STA as evidence is available only from a single RCT. In conclusion, the ERG considers that patients with metastatic SCCHN were not shown to receive a significant survival benefit from cetuximab plus CTX compared with CTX alone and that even setting a lower price for cetuximab would not strengthen the manufacturer's case for cost-effectiveness.

Use of Fourier-transform infrared spectroscopy for the diagnosis of failure of transfer of passive immunity and measurement of immunoglobulin concentrations in horses.

BACKGROUND: The economic, accurate, and rapid screening of foals for failure of transfer of passive immunity (FPT) is essential to ensure timely intervention. HYPOTHESIS: Infrared (IR) spectroscopy of foal sera and pattern recognition may be used to diagnose FPT and quantify serum IgG. SAMPLES: Sera from 194 foals (24-72 hours) with serum immunoglobulin G (IgG) concentrations determined previously by radial immunodiffusion assay (RID) were used. METHODS: IR spectra were recorded for the serum samples, and the data were randomly divided into training and independent test sets, each containing both FPT-positive (IgG <400 mg/dL) and non-FPT samples. A genetic optimal region selection algorithm and linear discriminant analysis were used to partition the training spectra, and the resulting classifier was then validated by comparing the IR-predicted FPT status for each of the test samples to that provided by the RID IgG assay. A quantitative IR-based assay for IgG was developed using partial least squares (PLS) and validated by testing its ability to predict IgG concentrations. RESULTS: Specificity, sensitivity, and accuracy for the combined data were 92.5, 96.8, and 95.9%, respectively. Corresponding positive (88.1%) and negative predictive (98.0%) values determined a success rate of 95-97% as compared to RID-based IgG concentrations. The IR-based quantitative assay yielded correlation coefficients for IR spectroscopy versus RID-based IgG concentrations of 0.90 and 0.86 for the training and test sets, respectively. CONCLUSIONS AND CLINICAL IMPORTANCE: The overall performance of the IR-based test was similar to that of the colorimetric assay and was superior and more economic than other available tests.

Decision tools for life support: a review and policy analysis.

OBJECTIVE: To identify, describe, and compare published documents intended to guide decisions about the administration, withholding, or withdrawal of life support in critical care. DESIGN: Review article. SETTING AND SOURCES: Publicly available, English-language guidelines or decision tools for life support, identified through systematic literature search. MEASUREMENTS AND MAIN RESULTS: Forty-nine documents were included and coded for authorship, source, development methodology, format, and positions taken on 12 common life-support issues. Sources were independent academics (n=21, 43%), professional organizations (n=19, 44%), and provider organizations. Eighteen documents (37%) described no development method. Twenty-three (47%) were produced collectively (e.g., by committees or consensus conference), 7 (14%) mentioned a literature review, and 2 (4%) were based upon the author's professional experience. Tools differed in format and focus; we characterize three types as decision schemas (involving clinical practice algorithms; n=7, 14%), decision guides (reviewing legal or professional positions; n=29, 59%), and decision counsels (more discursive and focusing typically on ethical issues; n=13, 27%). Tools addressed 12 common life-support issues: advance directives (67%), resource considerations (51%), ICU discharge criteria (27%), ICU admission criteria (16%), whether withholding differs from withdrawing life support (59%), whether nutrition and hydration decisions are different from decisions about other types of life support (61%), euthanasia (49%), double effect (47%), brain death (35%), special considerations for patients in a persistent vegetative state (51%), potential organ donors (12%), and pregnant patients (10%). Positions on these key life-support issues varied. CONCLUSIONS: Published tools for guiding life-support decisions vary widely in their genesis, authorship, format, focus, and practicality. They also differ in their attention to, and positions on, key life-support dilemmas. Future research on decision tools should focus on how users interpret and apply the messages in these tools and their impacts on practice, quality of care, participant experiences, and outcomes.

Adverse events and near miss reporting in the NHS.

OBJECTIVES: To conduct a multicentre study on adverse event and near miss reporting in the NHS and to explore the feasibility of creating a national system for collecting these data. DESIGN: Prospective voluntary reporting by staff with anonymised transfer of data was used by a national system to collect data from 18 NHS trusts. PARTICIPANTS: Staff from 12 acute trusts, three mental health trusts, two ambulance trusts, and one primary care trust. MAIN OUTCOMES MEASURED: Number of incidents, date and time of incident, patient age and sex, clinical speciality, location, outcome, risk rating, type and description of incident. RESULTS: A total of 28 998 incidents were reported including 11 766 (41%) slips, trips and falls, 2514 (9%) medication management incidents, 2429 (8%) resource issues, and 2164 (7%) treatment issues. 138 catastrophic and 260 major adverse outcomes were reported. Slips, trips and falls (n = 11 766) were the most common type of incident. CONCLUSIONS: Voluntary reporting by staff when linked to a multicentre data collecting system can yield information on a large number of incidents. This provides support for the principle of creating a national IT system to collect and analyse incident data.

Assessment of optical path length in tissue using neodymium and water absorptions for application to near-infrared spectroscopy.

Quantitative analysis of blood oxygen saturation using near-IR spectroscopy is made difficult by uncertainties in both the absolute value and the wavelength dependence of the optical path length. We introduce a novel means of assessing the wavelength dependence of path length, exploiting the relative intensities of several absorptions exhibited by an exogenous contrast agent (neodymium). Combined with a previously described method that exploits endogenous water absorptions, the described technique estimates the absolute path length at several wavelengths throughout the visible/near-IR range of interest. Isolated rat hearts (n = 11) are perfused separately with Krebs-Henseleit buffer (KHB) and a KHB solution to which neodymium had been added, and visible/near-IR spectra are acquired using an optical probe made up of emission and collection fibers in concentric rings of diameters 1 and 3 mm, respectively. Relative optical path lengths at 520, 580, 679, 740, 800, 870, and 975 nm are 0.41+/-0.13, 0.49+/-0.21, 0.90+/-0.09, 0.94+/-0.01, 1.00, 0.84+/-0.01, and 0.78+/-0.08, respectively. The absolute path length at 975 nm is estimated to be 3.8+/-0.6 mm, based on the intensity of the water absorptions and the known tissue water concentration. These results are strictly valid only for the experimental geometry applied here.

Adaptive management and its role in managing Great Barrier Reef water quality.

Adaptive management is the pathway to effective conservation, use and management of Australia's coastal catchments and waterways. While the concepts of adaptive management are not new, applications involving both assessment and management responses are indeed limited at the national and regional scales. This paper outlines the components of a systematic framework for linking scientific knowledge, existing tools, planning approaches and participatory processes to achieve healthy regional partnerships between community, industry, government agencies and science providers to overcome institutional barriers and uncoordinated monitoring. The framework developed by the Coastal CRC (www.coastal.crc.org.au/amf/amf/_index.htm) is hierarchical in the way it displays information to allow associated frameworks to be integrated, and represents a construct in which processes, information, decision tools and outcomes are brought together in a structured and transparent way for adaptive catchment and coastal management. This paper proposes how an adaptive management approach could be used to benefit the implementation of the Reef Water Quality Protection Plan (RWQPP).

Standards for gene therapy clinical trials based on pro-active risk assessment in a London NHS Teaching Hospital Trust.

Conducting gene therapy clinical trials with genetically modified organisms as the vectors presents unique safety and infection control issues. The area is governed by a range of legislation and guidelines, some unique to this field, as well as those pertinent to any area of clinical work. The relevant regulations covering gene therapy using genetically modified vectors are reviewed and illustrated with the approach taken by a large teaching hospital NHS Trust. Key elements were Trust-wide communication and involvement of staff in a pro-active approach to risk management, with specific emphasis on staff training and engagement, waste management, audit and record keeping. This process has led to the development of proposed standards for clinical trials involving genetically modified micro-organisms.

World Health Report 2000 "Financial fairness indicator": useful compass or crystal ball?

The World Health Report 2000 generated a huge amount of controversy when it set out to rank the performance of national health systems using data, statistical measures, and an explanatory rationale that were neither well understood nor broadly accepted. This article demystifies the conceptual and empirical underpinnings of the report's "financial fairness index," which resulted in country rankings that often seem counterintuitive. The author concludes that the index is seriously flawed, that rankings produced by the index should not be used, and that future WHO reports should avoid imputing financial fairness scores for countries that do not have real data.

Noninvasive assessment of cardiac ischemic injury using (87)Rb and (23)Na MR imaging, (31)P MR, and optical spectroscopy.

The aim of the study was to compare and analyze different noninvasive indices of cell damage in the isolated pig heart model of regional ischemia. We used (23)Na and (87)Rb MR imaging to evaluate Na(+)/K(+) balance, (31)P MR spectroscopy to measure energetics, and optical spectroscopy to assess oxymyoglobin (MbO(2)). Hearts were subjected to 120-min occlusion of the left anterior descending artery and were then reperfused for 120 min. Reperfusion resulted in an increase in (23)Na (37 +/- 18% of the posterior wall) and decrease in (87)Rb (55 +/- 15%) image intensities, partial recovery of PCr, ATP, the total phosphates, and MbO(2) in the anterior wall. The above changes are consistent with the irreversible cell damage in the anterior wall, confirmed by lack of staining with triphenyltetrazolium chloride. Changes in Na(+) and Rb(+) in the infarct area inversely correlated and their ratio is a more sensitive index of cell injury than either of them alone.

Genetic medicine: an experiment in community-expert interaction.

This project tested a two-way model of communication between lay groups and experts about genetic medicine in Perth, Western Australia. Focus group discussion with community group participants was followed by a communication workshop between community group participants and experts. Four groups of concerns or themes emerged from discussion: clinical considerations; legislative concerns; research priorities, and ethical and wider considerations. Community group concerns are not always met by the actions of "experts". This is, in part, because of the differing life-worlds of each group. However, the communication workshop showed the potential of two-way communication for both lay and expert members in understanding the others' viewpoint. Further, the approach developed here offers one possible way for community groups to participate in a substantial way in policy formulation processes.

Perceptions of women on the impact of menorrhagia on their health using multi-attribute utility assessment.

OBJECTIVE: To assess patient preferences regarding the treatment of menorrhagia using the multi-attribute utility methodologies, to produce a clinically applicable scale, and to assess health outcomes following treatment of menorrhagia. METHODS: Women referred to the gynaecology department for the treatment of menorrhagia were interviewed regarding the effects of menorrhagia on different aspects of their life. Their concerns were categorised into main components of health (domains). The relative importance of each domain was rated by the women using importance points which were distributed to represent the perceived importance of each domain. A series of statements (intra-domain statements) was developed for each domain, which described various possible conditions of that component of health. These were also rated using a one metre visual analogue scale with numerical anchor points at zero (worst) and 100 (best). RESULTS: The components of health considered most important were, in order of impact, family life, followed by physical health, work life, psychological health, practical difficulties and social life. The scores for the intra-domain statements were combined into a scale to allow the calculation of a final health state utility for a particular outcome based upon the statements the patient chooses within each domain. DISCUSSION: In planning treatment for menorrhagia clinicians can assess a woman's current perception of their health, using a simple to administer clinical scale.