Cost minimisation analysis of using acellular dermal matrix (Strattice™) for breast reconstruction compared with standard techniques.

BACKGROUND: We performed a cost analysis (using UK 2011/12 NHS tariffs as a proxy for cost) comparing immediate breast reconstruction using the new one-stage technique of acellular dermal matrix (Strattice™) with implant versus the standard alternative techniques of tissue expander (TE)/implant as a two-stage procedure and latissimus dorsi (LD) flap reconstruction. METHODS: Clinical report data were collected for operative time, length of stay, outpatient procedures, and number of elective and emergency admissions in our first consecutive 24 patients undergoing one-stage Strattice reconstruction. Total cost to the NHS based on tariff, assuming top-up payments to cover Strattice acquisition costs, was assessed and compared to the two historical control groups matched on key variables. RESULTS: Eleven patients having unilateral Strattice reconstruction were compared to 10 having TE/implant reconstruction and 10 having LD flap and implant reconstruction. Thirteen patients having bilateral Strattice reconstruction were compared to 12 having bilateral TE/implant reconstruction. Total costs were: unilateral Strattice, £3685; unilateral TE, £4985; unilateral LD and implant, £6321; bilateral TE, £5478; and bilateral Strattice, £6771. CONCLUSIONS: The cost analysis shows a financial advantage of using acellular dermal matrix (Strattice) in unilateral breast reconstruction versus alternative procedures. The reimbursement system in England (Payment by Results) is based on disease-related groups similar to that of many countries across Europe and tariffs are based on reported hospital costs, making this analysis of relevance in other countries.

How good are case notes in the audit of radiological investigations?

Audit based on the use of case notes completed in the ordinary course of patient care has not been widely used because of concern about the completeness and adequacy of such records. This paper describes the results of a study carried out to assess whether information contained in case notes was sufficiently reliable to enable clinical effectiveness to be measured. The study examines the extent to which a radiologist and an epidemiologist agree with two experienced clinicians in making retrospective judgements on whether out-of-hours radiological investigations are worthwhile. There was a high measure of agreement; only a relatively small amount of information in the case notes is needed to make valid judgements on clinical performance. The method described here may be applicable to other diagnostic investigations and the results of the study have wide implications for more effective and efficient management of resources within the NHS.

People's knowledge of health and disease.

A community survey based on the Cardiff electoral register was carried out in 1986. Seven hundred and ten adults were asked 10 open-ended questions about common serious illnesses in the United Kingdom and were given 18 statements about common diseases and asked to state whether they were true or false. This paper reports their responses. Amongst those gaining the highest scores there were more young people, more females, more from social classes I and II and more who had been educated to college or university level. We discuss the implications of the results for patient behaviour and for health education programmes.

Characteristics of self-reported hearing problems in a community survey.

The Cardiff Health Survey included a question asking whether the respondents had any difficulties with their hearing and, if so, to specify the biggest difficulty. This self-completed questionnaire was administered to 4,266 individuals randomly sampled from the electoral register of Cardiff in 1986. 14.7% of those responding indicated a hearing disability; and the main specific disabilities listed are described. The commonest complaints were of difficulties hearing the television and radio, and with general conversation. A number of other specific complaints were reported similar to those found in previous studies with the 'Problems Questionnaire'. Age, social class, general health, smoking and the individual's attitudes were found to influence the pattern of response.

Choosing who shall not be treated in the NHS.

In the face of severe resource constraints, health care systems are seeking both to control costs and to ensure maximum benefits for the resources consumed. The use of Quality Adjusted Life Years (QALYs) is becoming more widely advocated as a decision aid in the solution of resource allocation problems. The QALY combines two dimensions of health outcome--the quantity of life and its quality--in such a way that choices between different services with different purposes can be made using comparisons based on common units of measurement. The combination of these two dimensions allows comparisons between services with different objectives, such as curing and caring services. The QALY, however, lacks a third dimension which is vital to the decision-making process to which it is intended to contribute: the worth of a specific life relative to others. This paper presents results based on interviews of 719 residents of Cardiff drawn at random from the electoral register. The results suggest that further development of the novel methodology used to establish the relative value placed on various human lives is worthwhile. Evidence is given which indicates that the public consider lives to be of unequal worth. The results also show that these values are consistent for different types of choices phrased in different ways on a large number of control variables, implying the existence of a cultural stable value system which is a necessary prerequisite if consensus values of human life are to be used to assist decision-making in non-private health care systems.(ABSTRACT TRUNCATED AT 250 WORDS)

A survey of the appropriateness of the public's responses to hypothetical medical problems.

In a community survey based on the Cardiff electoral register a sample of 737 adults were questioned about what they would do in certain illness situations. The 20 hypothetical situations varied in terms of the age of the patient and the severity and seriousness of the illness. People were asked to choose from 13 reactions of differing urgency from taking home remedies, going to bed or staying indoors to dialling 999 and calling an ambulance.The authors' perceptions of the appropriateness of the reactions often did not match that of the public. In some situations, notably those involving changed bowel habits, black motions and high temperature with stiff neck, the public were thought to under-react, while in other cases, for example those involving bleeding, there was a tendency to over-react. Women were more likely than men to make appropriate responses, as were those in social classes 1 and 2. Those whose education was limited only to elementary or secondary school were more likely to be defined as overreactors or changers. These same characteristics were observed in the over-65-year-olds.Although the methodology described in this paper needs further development, the study points to a number of conditions where the public seems more or less concerned than the medical profession. It also suggests that health education programmes could pay more attention to illness behaviour.

A community survey of alcohol consumption.

A survey by 150 trained medical students was carried out in 1986 on a random sample of adults from the electoral register of Cardiff. The survey explored attitudes, knowledge and behaviour over a wide range of health related topics. 4266 self-completed questionnaires were returned for analysis and this paper reports the answers to the question 'how much did you drink last week'. The total units of alcohol were calculated and the drinking characteristics of the respondents are presented by age, sex, marital status, social class, accommodation and occupation. The contribution that such community surveys play in the development of local alcohol policy is discussed.

Out-of-hours radiology: a suitable case for audit?

An outline of radiological activity outside normal working hours over a 2-month period in a teaching hospital is presented. A 100-fold variation between specialties in the number of requests per 100 discharges and deaths is shown. Specialties with a high out-of-hours radiology demand also tended to have a high overall demand. Chest and abdomen radiographs accounted for approximately 82% of all investigations undertaken during the period of observation. Six radiological investigations--chest and abdomen radiographs, computed tomography, skull radiographs, intravenous urography and cardiac catheterisation--accounted for approximately 94% of all out-of-hours investigations. There was a 5.6-fold variation between investigations in the time taken to carry out one standard unit of work. In the health authority studied, it was estimated that pounds 93,000 was spent on radiographers' out-of-hours payments in 1984/85, of which almost 90% was directly related to the number of radiological procedures undertaken. It is suggested that the wide variation in rates of out-of-hours radiology usage between specialties requires more detailed examination. The limited range of procedures accounting for the great majority of the out-of-hours work makes a study feasible. The very marked variation in the time taken for one unit of work may result in important financial distortions if clinical budgeting becomes more widespread. The large excess cost of out-of-hours radiological investigations, which may be as much as pounds 16,000,000 per annum in England and Wales, offers the possibility of substantial savings if some of the investigations are shown to be of little clinical value outside normal working hours.

The cost of saving a life through cervical cytology screening: implications for health policy.

Through a review of the published literature on routine cervical cytology screening, this paper seeks to establish a likely range for the cost of saving a life through this screening programme as presently organised in England and Wales. The current performance of the programme may be expressed in several ways: a cost of 270,000 pounds to 285,000 pounds per life saved, 40,000 smears and 200 excision biopsies per death averted, or 1000 to 1500 avoidable deaths annually in England and Wales alone. The policy problems are thus of two kinds. First, there is a substantial misallocation of the limited resources available to an insurance based system of health care. Further, the money which is spent on this service does not avoid the mortality and morbidity which could reasonably be expected if the system were performing adequately. It is suggested that substantial improvements in the performance of the programme may well be possible if managers are appointed. Nevertheless a deeper policy issue is raised: to be delivered efficiently, any service based on population rather than individual considerations will require some acceptance by the medical profession of a limit to their traditional view of clinical freedom. The unresolved clash between population and individual considerations which poses such a fundamental challenge for policy making in insurance based health services is particularly well illustrated by the dilemma of publicly funded cervical cytology screening.

Can the use of radiography of arms and legs in accident and emergency units be made more efficient?

The efficiency of the selection of patients with injured arms and legs for radiography was investigated. The analysis was based on data on presenting signs and symptoms collected in a multicentre study organised by the Royal College of Radiologists working party on the effective use of diagnostic radiology. The work was carried out in eight accident and emergency units in England and Wales. With the help of various computer simulation techniques a combination of signs and symptoms that might usefully improve present practice was sought. The results suggest that for injuries of arms and legs the clinical determinants of bony injury cannot be refined further to improve current selection for radiography. This study shows that existing clinical practice is probably as good as it can be.

The distinction between worth and affordability: implications of costs and benefits for the allocation of health care resources.

There is an important distinction between worth and affordability which remains largely unrecognized. It is widely supposed that if an economic analysis shows that the benefits of a service exceed its costs, failure to fund it is irrational and inefficient. By means of a simplified model of a health care system, it is shown that although an excess of benefits over costs is a necessary precondition for providing a service, it is by no means sufficient. If society is to make the best use of its resources in health care, worthwhile services--those which make a social 'profit'--must be compared with other such services. Since the resources available to any health care system will always be limited, it is likely that not all services whose benefits exceed their costs can be afforded, because the budget has already been committed to those worthwhile services which yield higher benefits per unit cost.

Risk targetting: an approach to cost-containment.

The need for rationing in an insurance-based system of health care is inescapable. The best way to tackle the mismatch between demand and supply is, however, not clear. Of the four general strategies described, increasing the risk of disease in a population is shown to be the most effective way of reducing the outcome cost of a service. This may enable health care systems to provide services which would otherwise be unaffordable. This paper develops a technique for assessing risk using Lorenz curves which could be used by health service managers and clinicians. The paper uses cervical cytology screening to illustrate how variables can be selected in such a way as to maximise the number of potential beneficiaries while minimising the number of people to whom the service is offered.

How much can the NHS afford to spend to save a life or avoid a severe disability?

KIE: A measure termed the "benefit:premium ratio" is proposed to determine whether certain screening programs or high technology procedures are too expensive for Britain's National Health Service (NHS). Given that the NHS budget is finite, some programs, though proven effective, violate the principle of equity and reduce the benefits available to all subscribers. Since programs such as cervical and breast cancer screening, and routine preoperative chest X-rays, are aimed at eliminating infrequent risks, their cost is higher than warranted for an insurance-based system of health care. On the other hand, procedures such as renal transplantation, blood pressure screening, and open heart surgery are affordable according to the benefit:premium formula.^ieng