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Nelson, D. "Service innovations: the Orchard Clinic: Scotland's first medium secure unit." Psychiatric Bulletin 27, no. 03 (March 2003): 105–7. http://dx.doi.org/10.1192/s0955603600001641.
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The development of forensic psychiatry provision in Scotland lags behind that in other parts of the United Kingdom. Until recently, there were no medium secure units in the country and mentally disordered offenders (MDOs) requiring such care had to be managed in intensive psychiatric care unit (IPCU) settings. In November 2000, The Orchard Clinic, a medium secure unit sited at the Royal Edinburgh Hospital, was opened. This paper discusses the background to this development, the government policies setting out plans for the care, services and support of MDOs in Scotland, progress and work of the new unit to date and plans for developments in other parts of Scotland.
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Nelson, D. "Service innovations: the Orchard Clinic: Scotland's first medium secure unit." Psychiatric Bulletin 27, no. 3 (March 2003): 105–7. http://dx.doi.org/10.1192/pb.27.3.105.
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The development of forensic psychiatry provision in Scotland lags behind that in other parts of the United Kingdom. Until recently, there were no medium secure units in the country and mentally disordered offenders (MDOs) requiring such care had to be managed in intensive psychiatric care unit (IPCU) settings. In November 2000, The Orchard Clinic, a medium secure unit sited at the Royal Edinburgh Hospital, was opened. This paper discusses the background to this development, the government policies setting out plans for the care, services and support of MDOs in Scotland, progress and work of the new unit to date and plans for developments in other parts of Scotland.
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Laird, Siobhan E., Kate Morris, Philip Archard, and Rachael Clawson. "Changing practice: The possibilities and limits for reshaping social work practice." Qualitative Social Work 17, no. 4 (January 9, 2017): 577–93. http://dx.doi.org/10.1177/1473325016688371.
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Since 2010, the United Kingdom has witnessed a number of initiatives that shift away from reliance on performance management to improve social work with children and families, towards a renewed interest in practice models. This study reports on the evaluation of a local government programme in England to introduce and embed systemic family practice through the roll out of intensive training to social workers and frontline managers. It was anticipated through the programme that child protection social workers would undertake more direct work with families and build more positive relationships, resulting in a fall in the number of child protection plans and children experiencing repeat periods of care. The evaluation adopted a mixed-method approach encompassing an online survey of social workers, interviews with team managers and family members, a case audit and statistical analysis of local level metrics. It found limited employment of systemic family practice or improvement due to the programme. Adopting the 7 S framework, this study examines the barriers to and facilitators of successful change and identifies generic considerations for change programmes in child protection social work.
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Fong, Stephanie, and Patricia Morley-Forster. "Pain management training in undergraduate medical education." University of Western Ontario Medical Journal 87, no. 1 (April 24, 2018): 16–18. http://dx.doi.org/10.5206/uwomj.v87i1.1790.
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The pain curriculum in medical education across the globe is lacking, leaving medical trainees ill prepared to properly assess and design plans to address acute and chronic pain. Poorly managed pain has implications on the individual in the form of psychological, physical, and financial costs, and on the greater healthcare system and economy. Gaps in education have resulted in suboptimal opioid prescribing habits contributing to the current opioid epidemic, and the development of negative attitudes towards patients with chronic pain amongst healthcare providers. Studies researching existing pain education in undergraduate medical education in North America, the United Kingdom, and Europe have identified limited pain teaching, typically incorporated into other courses rather than given a designated place in the curriculum. Several barriers to improving the provision of pain education have been identified, including resource limitations and perceived importance in comparison to other content. Improving pain education in Canada should be a priority given recent updates to the Canadian Guideline for Opioid Therapy and Chronic Noncancer Pain which recommends a decrease to the maximum dose of morphine. Implementing these guidelines will require physicians to have the knowledge and ability to safely taper patients whose opioid doses exceed the upper limit. Enhancing pain education will require an interdisciplinary approach with students developing competence not only in the identification and appropriate management of pain, but learning the communication and motivational interviewing skills to display empathy and compassion when providing care to the chronic pain patient population.
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Stevens, Andrew, Claire Packer, and Glenn Robert. "Early Warning of New Health Care Technologies in the United Kingdom." International Journal of Technology Assessment in Health Care 14, no. 4 (1998): 680–86. http://dx.doi.org/10.1017/s0266462300011995.
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AbstractIn this paper we describe the present range of organizations that have a role in the early warning of new and emerging health care technologies in the United Kingdom. We discuss in more detail the processes and prioritization criteria used by the U.K. horizon-scanning project for the NHS Health Technology Assessment Programme, and the principal methods of technology identification for the horizon-scanning project are outlined. The United Kingdom plans to develop an integrated system for the identification of technologies for commercial planning, health service research prioritization, financial planning, and provision of information to policy makers, purchasers, and providers of health care.
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Farrell, Margaret G. "ERISA Preemption and Regulation of Managed Health Care: The Case for Managed Federalism." American Journal of Law & Medicine 23, no. 2-3 (1997): 251–89. http://dx.doi.org/10.1017/s0098858800010728.
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The result ERISA compels us to reach means that the Corcorans [who lost their unborn child allegedly as a result of United Healthcare’s negligent determination that hospitalization was not medically necessary] have no remedy, state or federal, for what may have been a serious mistake. This is troubling....In the words of its sponsor, Senator Jacob Javits, the Employee Retirement Income Security Act (ERISA) was enacted in 1974 “to maintain the voluntary growth of private [pension and employee benefit] plans while at the same time making needed structural reforms in such areas as vesting, funding, termination, etc. so as to safeguard workers against loss of their earned or anticipated benefits....” Ironically, one of ERISA’s provisions—its indeterminate provision for the preemption of state law—has probably created more uncertainty about the adequacy and security of health care benefits than any other piece of legislation. Neither ERISA nor any other federal statute comprehensively regulates the content of employer provided health care plans, including benefits provided through managed care organizations (MCOs).
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Crowcroft, N., D. W. Brown, and R. Gopal. "Current management of patients with Viral Haemorrhagic Fevers in the United Kingdom." Eurosurveillance 7, no. 3 (March 1, 2002): 44–48. http://dx.doi.org/10.2807/esm.07.03.00339-en.
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In the UK, suspected and confirmed cases of viral haemorrhagic fever are currently managed according to the 1996 Guidance of the Advisory Committee on Dangerous Pathogens, which describes an approach to the risk categorisation of suspected cases. It also provides guidance on patient management including transfer, laboratory investigations, infection control, and monitoring of contacts based on the risk assessment. Confirmed cases are managed in bed isolators ("Trexler units"), two of which are available in high security infectious disease units in the UK. This guidance is under review and may change. Recent experience has shown that communication and reassurance for health care workers and the public are major tasks in managing such cases.
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Ng, Judy, Faye Ye, Lindsey Roth, Katherine Sobel, Sepheen Byron, Mary Barton, Megan Lindley, and Shannon Stokley. "Human Papillomavirus Vaccination Coverage Among Female Adolescents in Managed Care Plans — United States, 2013." MMWR. Morbidity and Mortality Weekly Report 64, no. 42 (October 30, 2015): 1185–89. http://dx.doi.org/10.15585/mmwr.mm6442a1.
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Mason, Heather, Nicole Schnackenberg, and Robin Monro. "Yoga and Healthcare in the United Kingdom." International Journal of Yoga Therapy 27, no. 1 (November 1, 2017): 121–26. http://dx.doi.org/10.17761/1531-2054-27.1.121.
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Abstract The emergence of yoga therapy in the United Kingdom began about 45 years ago with the emergence of yoga therapy organizations that offered both treatment and training. The integration of yoga into the National Health Service (NHS) is gradually happening Because: (a) yoga research supports its efficacy as a cost-effective, preventive and complementary treatment for a host of non-communicable diseases; and (b) the escalating economic burden of long-term conditions is overwhelming the NHS. The NHS is actively developing ‘sustainability and transformation plans’ that include yoga. Chief among these is ‘social prescribing,’ which empowers patients with complex health needs through activities groups. These activities reduce sedentary habits and social isolation, while helping patients to be more self-reliant. The NHS has allocated £450 million in funding to implement a variety of programs for its own staff, in which staff yoga classes were expressly mentioned. The yoga community is mobilizing forces and applying for funding to pilot relevant NHS staff yoga courses that can support the service in achieving its vision. Research shows that integrating yoga therapy for the treatment of low back pain (LBP) into the NHS would result in significant cost savings as compared with usual care. The National Institute for Health and Care Excellence (NICE) Guidelines on LBP and sciatica include yoga as one of the recommended treatments for these conditions. Three groups of yoga teachers, using different yoga practices, have gained traction with the NHS for the application of yoga therapy to LBP. Many regional hospitals in England have yoga classes. The NHS Choices website, which conveys information to the public regarding treatment options, has a page dedicated to the health benefits of yoga. Several institutions offer comprehensive training programs in yoga therapy and yoga therapy is recognized as an official profession. The Yoga in Healthcare Alliance has been established to help integrate yoga therapy into the NHS. This consists of parliamentarians, leaders in the NHS, yoga researchers, health professionals, and representatives from leading yoga organizations.
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Cocks, H., K. Ah-See, M. Capel, and P. Taylor. "Palliative and supportive care in head and neck cancer: United Kingdom National Multidisciplinary Guidelines." Journal of Laryngology & Otology 130, S2 (May 2016): S198—S207. http://dx.doi.org/10.1017/s0022215116000633.
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AbstractThis is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It provides recommendations on the assessments and interventions for this group of patients receiving palliative and supportive care.Recommendations• Palliative and supportive care must be multidisciplinary. (G)• All core team members should have training in advanced communication skills. (G)• Palliative surgery should be considered in selected cases. (R)• Hypofractionated or short course radiotherapy should be considered for local pain control and for painful bony metastases. (R)• All palliative patients should have a functional endoscopic evaluation of swallowing (FEES) assessment of swallow to assess for risk of aspiration. (G)• Pain relief should be based on the World Health Organization pain ladder. (R)• Specialist pain management service involvement should be considered early for those with refractory pain. (G)• Constipation should be avoided by the judicious use of prophylactic laxatives and the correction of systemic causes such as dehydration, hypercalcaemia and hypothyroidism. (G)• Organic causes of confusion should be identified and corrected where appropriate, failing this, treatment with benzodiazepines or antipsychotics should be considered. (G)• Patients with symptoms suggestive of spinal metastases or metastatic cord compression must be managed in accordance with the National Institute for Health and Care Excellence guidance. (R)• Cardiopulmonary resuscitation is inappropriate in the palliative dying patient. (R)• ‘Do not attempt cardiopulmonary resuscitation’ orders should be completed and discussed with the patient and/or the family unless good reasons exist not to do so where appropriate. This is absolutely necessary when a patient's care is to be managed at home. (G)
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Reddick, Christopher G. "Managed health care plans in Southern United States municipalities: empirical evidence on choice of plan." International Journal of Health Planning and Management 20, no. 2 (2005): 99–111. http://dx.doi.org/10.1002/hpm.801.
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Cahill, Michael T., and Peter D. Jacobson. "Pegram’s Regress: A Missed Chance for Sensible Judicial Review of Managed Care Decisions." American Journal of Law & Medicine 27, no. 4 (2001): 421–38. http://dx.doi.org/10.1017/s0098858800008200.
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Managed care was designed to bring stability and balance to healthcare delivery in the United States, but its experience in the legal system has involved only moderate stability and very little balance. There has been a trend toward broad deference to the industry, so that managed care organizations (MCOs) are largely immune from liability. At the same time, some courts have suggested that the entire managed care model rests on sketchy legal ground. Meanwhile, commentators have disagreed on such fundamental questions as whether legal disputes arising under managed care should be resolved according to contract law or tort law. Moreover, the extent to which the Employee Retirement Income Security Act of 1974 (ERISA) governs, or moots, patients’ claims against MCOs has never been entirely clear—and because ERISA controls a vast number of health insurance plans, this legal issue is extremely significant.
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Richards, Thomas B., Megan C. Lindley, Sepheen C. Byron, and Mona Saraiya. "Human Papilloma Virus Vaccination and Cervical Cancer Screening Coverage in Managed Care Plans—United States, 2018." Obstetrical & Gynecological Survey 77, no. 10 (October 2022): 585–87. http://dx.doi.org/10.1097/01.ogx.0000892148.56172.bf.
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Carter, C., D. Smith, and N. Tandon. "AB0927 Annual golimumab utilization and costs for psoriatic arthritis patients in united states managed care plans." Annals of the Rheumatic Diseases 71, Suppl 3 (June 2013): 691.15–691. http://dx.doi.org/10.1136/annrheumdis-2012-eular.927.
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Havighurst, Clark C. "Vicarious Liability: Relocating Responsibility For The Quality Of Medical Care." American Journal of Law & Medicine 26, no. 1 (2000): 7–29. http://dx.doi.org/10.1017/s0098858800010807.
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AbstractManaged health care has recently generated a great deal of distrust, even anger, in the public mind. To be sure, much of this public reaction is based on anecdotal evidence and one-dimensional thinking. But many unbiased experts observing managed care today are themselves unhappy with the health care industry's performance. While these observers find little justification for the current political backlash against managed care, they are also disappointed that today's health plans have not made a more positive difference. Indeed, informed observers commonly regret that the new arrangements for the financing and delivery of care have done so little to get physicians to adopt truly efficient practices, achieving not only cost reductions but also substantial improvements in health status and patient outcomes— that is, in the quality of care. Although managed care has not demonstrably harmed the overall quality of health care in the United States, it has done little to improve it.
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Pracy, P., S. Loughran, J. Good, S. Parmar, and R. Goranova. "Hypopharyngeal cancer: United Kingdom National Multidisciplinary Guidelines." Journal of Laryngology & Otology 130, S2 (May 2016): S104—S110. http://dx.doi.org/10.1017/s0022215116000529.
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AbstractThis is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. With an age standardised incidence rate of 0.63 per 100 000 population, hypopharynx cancers account for a small proportion of the head and neck cancer workload in the UK, and thus suffer from the lack of high level evidence. This paper discusses the evidence base pertaining to the management of hypopharyngeal cancer and provides recommendations on management for this group of patients receiving cancer care.Recommendations• Cross-sectional imaging with computed tomography of the head, neck and chest is necessary for all patients; magnetic resonance imaging of the primary site is useful particularly in advanced disease; and computed tomography and positron emission tomography to look for distant disease. (R)• Careful evaluation of the upper and lower extents of the disease is necessary, which may require contrast swallow or computed tomography and positron emission tomography imaging. (R)• Formal rigid endoscopic assessment under general anaesthetic should be performed. (R)• Nutritional status should be proactively managed. (R)• Full and unbiased discussion of treatment options should take place to allow informed patient choice. (G)• Early stage disease can be treated equally effectively with surgery or radiotherapy. (R)• Endoscopic resection can be considered for early well localised lesions. (R)• Bulky advanced tumours require circumferential or non-circumferential resection with wide margins to account for submucosal spread. (R)• Offer primary surgical treatment in the setting of a compromised larynx or significant dysphagia. (R)• Midline lesions require bilateral neck dissections. (R)• Consider management of silent nodal areas usually not addressed for other primary sites. (G)• Reconstruction needs to be individualised to the patients’ needs and based on the experience of the unit with different reconstructive techniques. (G)• Consider tumour bulk reduction with induction chemotherapy prior to definitive radiotherapy. (R)• Consider intensity modulated radiation therapy where possible to limit the consequences of wide field irradiation to a large volume. (R)• Use concomitant chemotherapy in patients who are fit enough and consider epidermal growth factor receptor blockers for those who are less fit. (R)
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Collen, M. F. "Historical Evolution of Preventive Medical Informatics in the USA." Methods of Information in Medicine 39, no. 03 (2000): 204–7. http://dx.doi.org/10.1055/s-0038-1634344.
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AbstractA major reorganization of healthcare services is occurring in the United States. It has evolved from the solo- and group-practice models of the 1940s with fee-for-service and insurer-indemnification financing that used paper-based information systems to support preventive medical services. In the 1990s there emerged nation-wide, managed-care plans employing enhanced computer-based information systems with online preventive medical practice guidelines and Internet-supported home-care telemedicine. It is helpful to review how this major reengineering of medicine has come about.
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Tornambe, Paul E. "The Impact of Ultra-widefield Retinal Imaging on Practice Efficiency." US Ophthalmic Review 10, no. 01 (2017): 27. http://dx.doi.org/10.17925/usor.2017.10.01.27.
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I n the current cost- and resource-constrained healthcare environment in the United States, characterized by declining government reimbursement and increased utilization scrutiny by managed care plans, providers are challenged to continue delivering quality care to more patients while also more effectively managing practice economics. Employing technology to improve practice efficiency is one of the most promising solutions to this dilemma. We have demonstrated that the integration of ultra-widefield (UWF) retinal imaging in our practice is cost-effective. It has allowed us to increase the number of patient encounters while simultaneously raising the quality of care, and increasing patient satisfaction.
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Thibodeau, Lise, Elham Rahme, James Lachaud, Éric Pelletier, Louis Rochette, Ann John, Anne Reneflot, Keith Lloyd, and Alain Lesage. "Status report - Individual, programmatic and systemic indicators of the quality of mental health care using a large health administrative database: an avenue for preventing suicide mortality." Health Promotion and Chronic Disease Prevention in Canada 38, no. 7/8 (August 2018): 295–304. http://dx.doi.org/10.24095/hpcdp.38.7/8.04.
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Suicide is a major public health issue in Canada. The quality of health care services, in addition to other individual and population factors, has been shown to affect suicide rates. In publicly managed care systems, such as systems in Canada and the United Kingdom, the quality of health care is manifested at the individual, program and system levels. Suicide audits are used to assess health care services in relation to the deaths by suicide at individual level and when aggregated at the program and system levels. Large health administrative databases comprise another data source used to inform population- based decisions at the system, program and individual levels regarding mental health services that may affect the risk of suicide. This status report paper describes a project we are conducting at the Institut national de santé publique du Québec (INSPQ) with the Quebec Integrated Chronic Disease Surveillance System (QICDSS) in collaboration with colleagues from Wales (United Kingdom) and the Norwegian Institute of Public Health. This study describes the development of quality of care indicators at three levels and the corresponding statistical analysis strategies designed. We propose 13 quality of care indicators, including system-level and several population-level determinants, primary care treatment, specialist care, the balance between care sectors, emergency room utilization, and mental health and addiction budgets, that may be drawn from a chronic disease surveillance system.
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Newlands, C., R. Currie, A. Memon, S. Whitaker, and T. Woolford. "Non-melanoma skin cancer: United Kingdom National Multidisciplinary Guidelines." Journal of Laryngology & Otology 130, S2 (May 2016): S125—S132. http://dx.doi.org/10.1017/s0022215116000554.
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AbstractThis is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. This paper provides consensus recommendations on the management of cutaneous basal cell carcinoma and squamous cell carcinoma in the head and neck region on the basis of current evidence.Recommendations• Royal College of Pathologists minimum datasets for NMSC should be adhered to in order to improve patient care and help work-force planning in pathology departments. (G)• Tumour depth is of critical importance in identifying high-risk cutaneous squamous cell carcinoma (cSCC), and should be reported in all cases. (R)• Appropriate imaging to determine the extent of primary NMSC is indicated when peri-neural involvement or bony invasion is suspected. (R)• In the clinically N0 neck, radiological imaging is not beneficial, and a policy of watchful waiting and patient education can be adopted. (R)• Patients with high-risk NMSC should be treated by members of a skin cancer multidisciplinary team (MDT) in secondary care. (G)• Non-infiltrative basal cell carcinoma (BCC) <2 cm in size should be excised with a margin of 4–5 mm. Smaller margins (2–3 mm) may be taken in sites where reconstructive options are limited, when reconstruction should be delayed. (R)• Where there is a high risk of recurrence, delayed reconstruction or Mohs micrographic surgery should be used. (R)• Surgical excision of low-risk cSCC with a margin of 4 mm or greater is the treatment of choice. (R)• High-risk cSCC should be excised with a margin of 6 mm or greater. (R).• Mohs micrographic surgery has a role in some high-risk cSCC cases following MDT discussion. (R)• Delayed reconstruction should be used in high-risk cSCC. (G)• Intra-operative conventional frozen section in cSCC is not recommended. (G)• Radiotherapy (RT) is an effective therapy for primary BCC and cSCC. (R)• Re-excision should be carried out for incompletely excised high-risk BCC or where there is deep margin involvement. (R)• Incompletely excised high-risk cSCC should be re-excised. (R)• Further surgery should involve confirmed marginal clearance before reconstruction. (R)• P+ N0 disease: Resection should include involved parotid tissue, combined with levels I–III neck dissection, to include the external jugular node. (R)• P+ N+ disease: Resection should include level V if that level is clinically or radiologically involved. (R)• Adjuvant RT should include level V if not dissected. (R)• P0 N+ disease: Anterior neck disease should be managed with levels I–IV neck dissection to include the external jugular node. (R)• P0 N+ posterior echelon nodal disease (i.e. occipital or post-auricular) should undergo dissection of levels II–V, with sparing of level I. (R)• Consider treatment of the ipsilateral parotid if the primary site is the anterior scalp, temple or forehead. (R)• All patients should receive education in self-examination and skin cancer prevention measures. (G)• Patients who have had a single completely excised BCC or low-risk cSCC can be discharged after a single post-operative visit. (G)• Patients with an excised high-risk cSCC should be reviewed three to six monthly for two years, with further annual review depending upon clinical risk. (G)• Those with recurrent or multiple BCCs should be offered annual review. (G)
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Mowat, A., P. Meakin, S. Anastasiadou, R. Bidaye, and S. Anari. "The management of posterior epistaxis in the United Kingdom, a national survey." Rhinology Online 5, no. 5 (January 31, 2022): 19–22. http://dx.doi.org/10.4193/rhinol/21.056.
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Background: Posterior bleeds account for 5% of epistaxis. The patient cohort is often elderly and has significant co-morbidities. Such cases have been managed historically with urinary catheters, held in place with umbilical clips. Recently bespoke, double balloon, posterior packs have been utilised. The treatments remain in clinical equipoise with no gold standard or clear national guideline. Methodology: A ten question survey was sent out through www.surveymonkey.com. Attempts were made to contact all Trusts in the United Kingdom via the ENT on call service. A comparison of treatment costs was made. Results: 112 responses have been received. 54% of respondents reported a preference for bespoke posterior pack insertion, only 12% preferred catheters. Twice as many respondents have seen complications from urinary catheters: 14% vs 29%. The availability of posterior packs is inconsistent: 30% of respondents were not aware of the packs or reported them unavailable in their hospital. Conclusions: This survey provides the first comparison of the techniques in the United Kingdom. Bespoke packs have a lower complication rate and are preferred by ENT clinicians on the front line of patient care. We recommend that all UK trusts should stock posterior packs which should be used as first line treatment for cases of posterior epistaxis.
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Powell, Adam, and Paul Dolan. "Moving to Personalized Medicine Requires Personalized Health Plans." Journal of Participatory Medicine 14, no. 1 (August 4, 2022): e35798. http://dx.doi.org/10.2196/35798.
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When individuals, families, and employers select health plans in the United States, they are typically only shown the financial structure of the plans and their provider networks. This variation in financial structure can lead patients to have health plans aligned with their financial needs, but not with their underlying nonfinancial preferences. Compounding the challenge is the fact that managed care organizations have historically used a combination of population-level budget impact models, cost-effectiveness analyses, medical necessity criteria, and current medical consensus to make coverage decisions. This approach to creating and presenting health plan options does not consider heterogeneity in patient and family preferences and values, as it treats populations as uniform. Similarly, it does not consider that there are some situations in which patients are price-insensitive. We seek to highlight the challenges posed by presenting health plans to patients in strictly financial terms, and to call for more consideration of nonfinancial patient preferences in the health plan design and selection process.
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Jhaveri, M., B. Seal, M. Pollack, and D. Wertz. "Will insomnia treatments produce overall cost savings to commercial managed-care plans? A predictive analysis in the United States." Current Medical Research and Opinion 23, no. 6 (May 17, 2007): 1431–43. http://dx.doi.org/10.1185/030079907x199619.
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Monie, Ian C. "The Visual Arts Library & Information Plan (VALIP): history of a campaign." Art Libraries Journal 22, no. 3 (1997): 26–32. http://dx.doi.org/10.1017/s0307472200010506.
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The concept of a Library and Information Plan (LIP) as an aid to better management and improved services was proposed in England in 1986, when gaps in library provision and the inadequacy of services were becoming apparent. In 1991 the Council of ARLIS/UK & Eire obtained a grant to draft a proposal for a research project, arguing the need for a LIP covering art, design and architecture information in the United Kingdom and the Republic of Ireland. Further funds were found to appoint a Steering Committee and a research consultant, and a Visual Arts Library and Information Plan (VALIP) was published in 1993. An Executive Committee was formed to negotiate the inclusion of VALIP in whatever national machinery came into existence. During that year the Secretary of State for National Heritage announced plans to create a new Library and Information Commission, but despite encouraging signs, government support was not given to fund a VALIP Manager. Progress was made with some parts of the VALIP programme of work, but the Steering Committee and the Executive Committee disbanded in 1997, leaving ARLIS to find other means of improving access to visual arts materials.
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Szcześniak, Dorota, Rose-Marie Dröes, Franka Meiland, Dawn Brooker, Elisabetta Farina, Rabih Chattat, Shirley B. Evans, et al. "Does the community-based combined Meeting Center Support Programme (MCSP) make the pathway to day-care activities easier for people living with dementia? A comparison before and after implementation of MCSP in three European countries." International Psychogeriatrics 30, no. 11 (February 13, 2018): 1717–34. http://dx.doi.org/10.1017/s1041610217002885.
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ABSTRACTBackground:The “pathway to care” concept offers a helpful framework for preparing national dementia plans and strategies and provides a structure to explore the availability and accessibility of timely and effective care for people with dementia and support for their informal carers. Within the framework of the JPND-MEETINGDEM implementation project the pathways to regular day-care activities and the Meeting Centers Support Programme (MCSP), an innovative combined support form for people with dementia and carers, was explored.Methods:An exploratory, descriptive, qualitative, cross-country design was applied to investigate the pathways to day care in several regions in four European countries (Italy, Poland, United Kingdom, and the Netherlands).Results:Before implementation of MCSP, of the four countries the United Kingdom had the most structured pathway to post-diagnostic support for people with dementia. MCSP introduction had a positive impact on the pathways to day-care activities in all countries. MCSP filled an important gap in post-diagnostic care, increasing the accessibility to support for both people with dementia and carers. Key elements such as program of activities, target group, and collaboration between healthcare and social services were recognized as success factors.Conclusions:This study shows that MCSP fills (part of) the gap between diagnosis and residential care and can therefore be seen as a pillar of post-diagnostic care and support. Further dissemination of Meeting Centers in Europe may have a multiple impact on the structure of dementia services in European countries and the pathways to day care for people with dementia and their carer(s).
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Resende, Tamiris Cristhina, Marco Antonio Catussi Paschoalotto, Stephen Peckham, Claudia Souza Passador, and João Luiz Passador. "How did the UK government face the global COVID-19 pandemic?" Revista de Administração Pública 55, no. 1 (February 2021): 72–83. http://dx.doi.org/10.1590/0034-761220200418.
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Abstract This paper aims to analyse the coordination and cooperation in Primary Health Care (PHC) measures adopted by the British government against the spread of the COVID-19. PHC is clearly part of the solution founded by governments across the world to fight against the spread of the virus. Data analysis was performed based on coordination, cooperation, and PHC literature crossed with documentary analysis of the situation reports released by the World Health Organisation and documents, guides, speeches and action plans on the official UK government website. The measures adopted by the United Kingdom were analysed in four periods, which helps to explain the courses of action during the pandemic: pre-first case (January 22- January 31, 2020), developing prevention measures (February 1 -February 29, 2020), first Action Plan (March 1- March 23, 2020) and lockdown (March 24-May 6, 2020). Despite the lack of consensus in essential matters such as Brexit, the nations in the United Kingdom are working together with a high level of cooperation and coordination in decision-making during the COVID-19 pandemic.
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Johnson, Eleanor K., Ailsa Cameron, Liz Lloyd, Simon Evans, Robin Darton, Randall Smith, Teresa Atkinson, and Jeremy Porteus. "Ageing in extra-care housing: preparation, persistence and self-management at the boundary between the third and fourth age." Ageing and Society 40, no. 12 (July 18, 2019): 2711–31. http://dx.doi.org/10.1017/s0144686x19000849.
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AbstractExtra-care housing (ECH) has been hailed as a potential solution to some of the problems associated with traditional forms of social care, since it allows older people to live independently, while also having access to care and support if required. However, little longitudinal research has focused on the experiences of residents living in ECH, particularly in recent years. This paper reports on a longitudinal study of four ECH schemes in the United Kingdom. Older residents living in ECH were interviewed four times over a two-year period to examine how changes in their care needs were encountered and negotiated by care workers, managers and residents themselves. This paper focuses on how residents managed their own changing care needs within the context of ECH. Drawing upon theories of the third and fourth age, the paper makes two arguments. First, that transitions across the boundary between the third and fourth age are not always straightforward or irreversible and, moreover, can sometimes be resisted, planned-for and managed by older people. Second, that operational practices within ECH schemes can function to facilitate or impede residents’ attempts to manage this boundary.
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Deane, K. H. O., C. Ellis-Hill, K. Dekker, P. Davies, and C. E. Clarke. "A Survey of Current Occupational Therapy Practice for Parkinson's Disease in the United Kingdom." British Journal of Occupational Therapy 66, no. 5 (May 2003): 193–200. http://dx.doi.org/10.1177/030802260306600503.
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Little is known about the current character of occupational therapy practice for Parkinson's disease in the United Kingdom. The study aimed to document this in order to inform plans for a future multicentre randomised controlled trial. Two hundred and forty-two occupational therapists that treated people with Parkinson's disease were sent a questionnaire regarding demographics, service organisation and therapy content. One hundred and sixty-nine occupational therapists (70%) responded. They had worked with people with Parkinson's disease for a median of 6 years and personally treated a median of 15 people with Parkinson's disease annually. Most (86%) were at senior grade or above; 87% worked in the National Health Service and 12% in social services. Forty per cent worked in specialist Parkinson's disease clinics. Most (79%) felt that they needed more specialist postgraduate training. Occupational therapists are employed in both health and social care settings. The character of the occupational therapy is often determined by the location in which it is provided. Current occupational therapy appears to focus on functional activities rather than on the wider social and psychological aspects of occupation. Many occupational therapists felt that they needed more specialist postgraduate training to treat people with Parkinson's disease effectively.
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Batchelor, Paul. "The Historical and Political Background to the Proposals for Local Commissioning of Primary Dental Care by Primary Care Trusts." Primary Dental Care os12, no. 1 (January 2005): 11–14. http://dx.doi.org/10.1308/1355761052894158.
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This paper provides a background to the changes that are about to occur in the system for primary oral healthcare delivery in the NHS. This is part of a far wider reform programme involving all public sector services. The challenges that the Government faces are not unique: all countries are striving to alter their care systems to address the changing expectations of the electorate while attempting to control both the costs and inequalities. What is unique to the United Kingdom is the historical legacy of the NHS and its political importance, which should not be underestimated. An overview of the agenda for change in all parts of the health sector is presented. This is followed by a more detailed analysis of the proposals for future delivery of primary oral care in the NHS and the subsequent issues arising. A consistent theme running throughout the Government's agenda is devolution. Indeed, the detailed programme discussed in this paper applies only to England and Wales. The fact that Scotland has different plans highlights the importance of the political and cultural setting to any reform programme.
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Garcia-Calvente, M. d. M., E. Castano-Lopez, I. Mateo-Rodriguez, G. Maroto-Navarro, and M. T. Ruiz-Cantero. "A tool to analyse gender mainstreaming and care-giving models in support plans for informal care: case studies in Andalusia and the United Kingdom." Journal of Epidemiology & Community Health 61, Supplement 2 (December 1, 2007): ii32—ii38. http://dx.doi.org/10.1136/jech.2007.060665.
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Knox, James, Chandini Chuni, Zehra Naqvi, Pam Crawford, and W. Stephen Waring. "Presentations to An Acute Medical Unit Due to Headache: A Review of 306 Consecutive Cases." Acute Medicine Journal 11, no. 3 (July 1, 2012): 144–50. http://dx.doi.org/10.52964/amja.0563.
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The United Kingdom National Health Service has recently prioritised the need for ambulatory care pathways for acute headache. The present study sought to better characterise patients referred to an Acute Medical Unit so as to inform pathway development. In 2011, York Hospital received 306 referrals due to acute headache, representing 3% of acute medical admissions. Investigations included CT scan (38%), lumbar puncture (38%), and MRI (18%); there were no specialised investigations in 26%, and 18% of patients were discharged on the day of presentation. Subarachnoid haemorrhage occurred in only 4 patients (1%), meningitis in 10 (3%), and intracranial tumour in 5 (2%). The findings indicate that a significant proportion of patients with acute headache could be managed by ambulatory care.
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Milkovich, John, Tim Hanna, Carolyn Nessim, Teresa M. Petrella, Louis Weatherhead, An-Wen Chan, Jonathan C. Irish, et al. "Restructuring Skin Cancer Care in Ontario: A Provincial Plan." Current Oncology 28, no. 2 (March 12, 2021): 1183–96. http://dx.doi.org/10.3390/curroncol28020114.
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There is a global rise in skin cancer incidence, resulting in an increase in patient care needs and healthcare costs. To optimize health care planning, costs, and patient care, Ontario Health developed a provincial skin cancer plan to streamline the quality of care. We conducted a systematic review and a grey literature search to evaluate the definitions and management of skin cancer within other jurisdictions, as well as a provincial survey of skin cancer care practices, to identify care gaps. The systematic review did not identify any published comprehensive skin cancer management plans. The grey literature search revealed skin cancer plans in isolated regions of the United Kingdom (U.K.), National Institute for Health and Care Excellence (NICE) guidelines for skin cancer quality indicators and regional skin cancer biopsy clinics, and wait time guidelines in Australia and the U.K. With the input of the Ontario Cancer Advisory Committee (CAC), unique definitions for complex and non-complex skin cancers and the appropriate cancer services were created. A provincial survey of skin cancer care yielded 44 responses and demonstrated gaps in biopsy access. A skin cancer pathway map was created and a recommendation was made for regional skin cancer biopsy clinics. We have created unique definitions for complex and non-complex skin cancer and a skin cancer pathways map, which will allow for the implementation of both process and performance metrics to address identified gaps in care.
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Salter, Brian. "Change in the British National Health Service: Policy Paradox and the Rationing Issue." International Journal of Health Services 24, no. 1 (January 1994): 45–72. http://dx.doi.org/10.2190/r4bm-k9al-rqpm-tf4b.
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The National Health Service of the United Kingdom is trapped in a policy paradox. On the one hand, the 1990 reforms encourage the devolution of power to local purchaser and provider units through the operation of the “internal market.” On the other, mechanisms of control and accountability are being revamped to produce a centrally managed system bound together by corporate contracts. The political frictions generated by this paradox are exacerbated by the problem of rationing health care in the face of apparently unlimited demand. This article examines the political problems faced by a single Health Authority as it sought to implement the changes required of it by the conflicting policies.
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Narayan, N., and Stephen Richard Gulliford. "Can Ambulatory Emergency Care have a positive impact on acute services?" Acute Medicine Journal 14, no. 3 (July 1, 2015): 125–31. http://dx.doi.org/10.52964/amja.0449.
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Ambulatory Emergency Care is a key component of the service for many Acute Medical units across the United Kingdom. A well-functioning ambulatory care unit facilitiates early senior review by a consultant and may reduce the need for hospital admission by managing patients along alternative safe clinical pathways. In this article, we present 12 months of data (January 2014-January 2015) from our Ambulatory Unit at Wrightington, Wigan and Leigh NHS Foundation Trust (WWL NHSFT), which demonstrates how many different conditions can be safely managed along ambulatory care pathways and how this can significantly contribute to postive patient satisfaction survey results and meeting the A&E 4 hour target for a medium-sized Acute Trust such as WWL NHSFT. We also emphasise that the key factors of co-location of ambulatory care with the Emergency Department along with dedicated medical and nursing staff are essential to the success of this model of care.
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Bulusu, Venkata Ramesh, Helen Hatcher, Richard Hardwick, Nicholas Carroll, Stephanie Pursglove, Vicki Save, Peter Safranek, and Helena Margaret Earl. "Ten-year prospective experience of gastrointestinal stromal tumors (GISTS) from the Cambridge GIST Study Group, United Kingdom." Journal of Clinical Oncology 31, no. 15_suppl (May 20, 2013): 10541. http://dx.doi.org/10.1200/jco.2013.31.15_suppl.10541.
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10541 Background: Cambridge GIST study group was formed in 2003. GIST specialist multidisciplinary team (MDT) and GIST clinic were established with central review of histology/pathology and management plans. We present our 10 year experience of a prospective database which formed the template for the United Kingdom national GIST registry. Methods: All patients (pts) who have been referred to the GIST MDT were included in the study. The following data was prospectively collected: patient demographics, presenting symptoms, site, size, histology including mutational data (where available) risk stratification of the GISTS, surgical interventions, systemic therapies, other tumours occurring in GIST pts. Results: 260 patients (pts) were reviewed in the GIST MDT. 29 pts had endoscopic/imaging diagnosis of a GIST and were not included in the final analysis. 41 pts had other tumours diagnosed when GIST was initially suspected. Histologically confirmed GISTS N=190. Male: Female 52%:48%. Median age 64 years (range 14-94), 4% <40years. 84% had surgical intervention (primary or metastatectomy), 9% had resections on imatinib/sunitinib. Tumour characteristics: Site: Stomach-73%, small bowel-16%, EGIST-4%, colorectal-3%, duodenum-3% and oesophagus-1%. Size 0.1-40 cm. Histology subtype: Spindle cell =84%, mixed=12% and epitheloid=4%. Miettinen risk stratification groups: High risk=27%, intermediate risk=16% and very low risk/low risk=57%. Mutational status results in 36 pts: exon 11=64%, PDGFRA= 14%, wild type=11%, exon 9=5.5%, exon 13=5.5%. 14% of GIST pts had other tumour either prior to diagnosis or during treatment/follow up of GISTS. Conclusions: This is the first prospective regional GIST registry data from UK. Our results mirror other large prospective series. GISTS should be managed by an experienced multidisciplinary specialist team to provide a high quality patient centred service.
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Dick, Alastair G., Dominic Davenport, Mohit Bansal, Therese S. Burch, and Max R. Edwards. "Hip Fractures in Centenarians: Has Care Improved in the National Hip Fracture Database Era?" Geriatric Orthopaedic Surgery & Rehabilitation 8, no. 3 (August 8, 2017): 161–65. http://dx.doi.org/10.1177/2151458517722104.
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Introduction: The number of centenarians in the United Kingdom is increasing. An associated increase in the incidence of hip fractures in the extreme elderly population is expected. The National Hip Fracture Database (NHFD) initiative was introduced in 2007 aiming to improve hip fracture care. There is a paucity of literature on the outcomes of centenarians with hip fractures since its introduction. The aim of this study is to report our experience of hip fractures in centenarians in the era since the introduction of the NHFD to assess outcomes in terms of mortality, time to surgery, length of stay, and complications. Methods: A retrospective case note study of all centenarians managed for a hip fracture over a 7-year period at a London district general hospital. Results: We report on 22 centenarians sustaining 23 hip fractures between 2008 and 2015. Twenty-one fractures were managed operatively. For patients managed operatively, in-hospital, 30-day, 3-month, 6-month, 1-year, 2-year, 3-year, and 5-year cumulative mortalities were 30%, 30%, 39%, 50%, 77%, 86%, 95%, and 100%, respectively. In-hospital mortality was 100% for those managed nonoperatively. Mean time to surgery was 1.6 days (range: 0.7-6.3 days). Mean length of stay on the acute orthopedic ward was 23 days (range: 2-51 days). Seventy-one percent had a postoperative complication most commonly a hospital-acquired pneumonia or urinary tract infection. Conclusion: Compared to a series of centenarians with hip fractures prior to the introduction of the NHFD, we report a reduced time to surgery. Mortality and hospital length of stay were similar.
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Birch, Rachael C., Kitty-Rose Foley, Allan Pollack, Helena Britt, Nicholas Lennox, and Julian N. Trollor. "Problems managed and medications prescribed during encounters with people with autism spectrum disorder in Australian general practice." Autism 22, no. 8 (September 15, 2017): 995–1004. http://dx.doi.org/10.1177/1362361317714588.
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Autism spectrum disorder is associated with high rates of co-occurring health conditions. While elevated prescription rates of psychotropic medications have been reported in the United Kingdom and the United States, there is a paucity of research investigating clinical and prescribing practices in Australia. This study describes the problems managed and medications prescribed by general practitioners in Australia during encounters where an autism spectrum disorder was recorded. Information was collected from 2000 to 2014 as part of the Bettering the Evaluation and Care of Health programme. Encounters where patients were aged less than 25 years and autism spectrum disorder was recorded as one of the reasons for encounter and/or problems managed ( n = 579) were compared to all other Bettering the Evaluation and Care of Health programme encounters with patients aged less than 25 years ( n = 281,473). At ‘autism spectrum disorder’ encounters, there was a significantly higher management rate of psychological problems, and significantly lower management rates of skin, respiratory and general/unspecified problems, than at ‘non-autism spectrum disorder’ encounters. The rate of psychological medication prescription was significantly higher at ‘autism spectrum disorder’ encounters than at ‘non-autism spectrum disorder’ encounters. The most common medications prescribed at ‘autism spectrum disorder’ encounters were antipsychotics and antidepressants. Primary healthcare providers need adequate support and training to identify and manage physical and mental health concerns among individuals with autism spectrum disorder.
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Davies, Linda M., and Michael F. Drummond. "Assessment of Costs and Benefits of Drug Therapy for Treatment-Resistant Schizophrenia in the United Kingdom." British Journal of Psychiatry 162, no. 1 (January 1993): 38–42. http://dx.doi.org/10.1192/bjp.162.1.38.
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An analysis was conducted on the basis of available data to assess the economic consequences of clozapine therapy for people with moderate to severe schizophrenia in long-stay institutions or staffed group homes, with a view to providing an estimate of the likely costs and benefits of the drug. Data from a cost-effectiveness study conducted in the US, supplemented by other literature sources, were used to construct a clinical decision tree for likely clinical outcomes for such patients. A panel of UK psychiatrists provided consensus on how these patients would have been managed in the UK. The costs associated with each patient outcome were estimated, and a sensitivity analysis performed to test the assumptions made. For the patients themselves, clozapine would lead to a net gain of 5.87 years of life with no disability or only mild disability. The base case analysis showed that the direct costs of using clozapine were £91 less per annum (or £1333 per lifetime) than for standard neuroleptic therapy, when the effect on all health-care resources was taken into account. In addition, the sensitivity analysis showed that clozapine would be cost-saving or cost-neutral under many different assumptions. A prospective health economic study with clozapine in the management of schizophrenia would be desirable to confirm these results.
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Laird, J., and MC Evershed. "The differential diagnosis and management of headaches in primary care and their relevance in the UK armed forces." Journal of The Royal Naval Medical Service 100, no. 3 (December 2014): 301–7. http://dx.doi.org/10.1136/jrnms-100-301.
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AbstractAs with the general population, headaches are commonly suffered by members of the United Kingdom Armed Forces. These are often managed by patients with over-the-counter medication without the involvement of healthcare professionals. Patients may present to medical teams when deployed because of limited access to over-the-counter medication or because of concerns about the cause of the headache. This article will examine the differential diagnosis and management of headaches in primary care as well as considering the occupational and operational aspects related to the Royal Navy (RN). The aim is to equip General Practitioners (GPs) and General Duties Medical Officers (GDMOs) with the clinical knowledge to diagnose various common forms of headaches and to detect the red flag symptoms that warrant further investigation. This article will also make specific reference to the service person and the impact of headaches on occupational functioning and operational capability.
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Foody, JoAnne M., Amie T. Joyce, Amy E. Rudolph, Larry Z. Liu, and Joshua S. Benner. "Cardiovascular outcomes among patients newly initiating atorvastatin or simvastatin therapy: A large database analysis of managed care plans in the United States." Clinical Therapeutics 30, no. 1 (January 2008): 195–205. http://dx.doi.org/10.1016/j.clinthera.2008.01.003.
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Olsson-Brown, Anna Claire, Mark Baxter, Caroline Dobeson, Laura Feeney, Rebecca Lee, Alec Maynard, Shagufta Mirza, et al. "Real-world outcomes of immune-related adverse events in 2,125 patients managed with immunotherapy: A United Kingdom multicenter series." Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020): 7065. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.7065.
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7065 Background: Immune-related adverse events (irAE) are a recognised complication of immune checkpoint inhibitor (ICI) therapy. Previous characterisation of irAEs has been limited to clinical trial or registry populations and small case series. Here we present a multi-centre, granular, real-world analysis of the prevalence and outcomes of irAEs experienced by patients managed within a single comprehensive public health service. Methods: A multi-centre retrospective analysis of 2125 consecutive patients treated with ICIs was undertaken across 12 centres. All patients were managed within the UK National Health Service outside of a trial setting between June 2016 and September 2018. Patients received either ICI monotherapy (MT) or combination therapy (CT). Data were collected using a standardised, pre-piloted, collection tool. IrAEs ≥ grade 2 or endocrinopathies of any grade were considered clinically significant and recorded as per the Common Terminology Criteria for Adverse Events (V5) (CTCAE). Descriptive statistics were employed using Stata v15 (College Station, TX). Results: Patients received αPD-1 (1757; 82%), combination αPD-1/αCTLA-4 (285, 13%), αCTLA-4 (51; 2%) and αPD-L1 (31; 1%) immunotherapy for malignant melanoma (961), non-small cell lung cancer (788) or renal cell carcinoma (335). The median age was 66 (MT) and 57 (CT). Clinically significant irAEs occurred in 732 (34%) individuals; 28% (524) on MT and 73% (208) on CT. Colitis (206,10%), thyroiditis (194, 9%), hepatitis (142, 7%) and dermatitis (126, 6%) were most commonly observed. Grade 1 endocrinopathies occurred in 20% (173) of cases. Grade 2 irAEs occurred in 43% (359), grade 3 31% (269) and grade 4 6% (51). The were 3 (0.4%) cases of grade 5 irAE; pneumonitis (2) and hepatitis, all following αPD-1 MT. 93% (680) required corticosteroids with 64% (490) requiring systemic corticosteroids and 11% (80) steroid sparing immunosuppression. 16% (336) of patients had pre-existing autoimmune disease of whom 40% (136) experienced irAEs. IrAEs led to admission in 42% (308) of cases, accounting for 2996 bed days. Length of stay was 7 days (1-67; IQR 4-13). Higher dependency care was required in 0.7% (15) of cases. Colitis (35%, 107) and hepatitis (25%, 77) accounted for the most admissions. Pneumonitis accounted for 3% (66) of irAEs but 12% of admissions. Conclusions: One third of patients experienced a clinically-significant irAE resulting in significant morbidity and admission burden highlighting the need for effective management strategies to optimise patient outcomes.
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Coleman, D. A. "Replacement migration, or why everyone is going to have to live in Korea: a fable for our times from the United Nations." Philosophical Transactions of the Royal Society of London. Series B: Biological Sciences 357, no. 1420 (April 29, 2002): 583–98. http://dx.doi.org/10.1098/rstb.2001.1034.
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This paper considers international migration in the context of population ageing. In many Western countries, the search for appropriate responses to manage future population ageing and population decline has directed attention to international migration. It seems reasonable to believe that international migrants, mostly of young working age, can supply population deficits created by low birth rates, protect European society and economy from the economic costs of elderly dependency, and provide a workforce to care for the elderly. Particular prominence has been given to this option through the publicity attendant on a report from the UN Population Division in 2000 on ‘replacement migration’, which has been widely reported and widely misunderstood. Although immigration can prevent population decline, it is already well known that it can only prevent population ageing at unprecedented, unsustainable and increasing levels of inflow, which would generate rapid population growth and eventually displace the original population from its majority position. This paper reviews these arguments in the context of the causes and inevitability of population ageing, with examples mostly based on UK data. It discusses various options available in response to population ageing through workforce, productivity, pensions reform and other means. It concludes that there can be no ‘solution’ to population ageing, which is to a considerable degree unavoidable. However, if the demographic regime of the United Kingdom continues to be relatively benign, future population ageing can be managed with tolerable inconvenience without recourse to increased immigration for ‘demographic’ purposes. At present (2001), net immigration to the United Kingdom is already running at record levels and is now the main engine behind UK population and household growth. By itself, population stabilization, or even mild reduction, is probably to be welcomed in the United Kingdom, although the issue has attracted little attention since the 1970s.
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Latimer, Nicholas R., Simon Dixon, and Rebecca Palmer. "COST-UTILITY OF SELF-MANAGED COMPUTER THERAPY FOR PEOPLE WITH APHASIA." International Journal of Technology Assessment in Health Care 29, no. 4 (October 2013): 402–9. http://dx.doi.org/10.1017/s0266462313000421.
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Objectives: The aim of this study was to examine the potential cost-effectiveness of self-managed computer therapy for people with long-standing aphasia post stroke and to estimate the value of further research.Methods: The incremental cost-effectiveness ratio of computer therapy in addition to usual stimulation compared with usual stimulation alone was considered in people with long-standing aphasia using data from the CACTUS trial. A model-based approach was taken. Where possible the input parameters required for the model were obtained from the CACTUS trial data, a United Kingdom-based pilot randomized controlled trial that recruited thirty-four people with aphasia and randomized them to computer treatment or usual care. Cost-effectiveness was described using an incremental cost-effectiveness ratio (ICER) together with cost-effectiveness acceptability curves. A value of information analysis was undertaken to inform future research priorities.Results: The intervention had an ICER of £3,058 compared with usual care. The likelihood of the intervention being cost-effective was 75.8 percent at a cost-effectiveness threshold of £20,000 per QALY gained. The expected value of perfect information was £37 million.Conclusions: Our results suggest that computer therapy for people with long-standing aphasia is likely to represent a cost-effective use of resources. However, our analysis is exploratory given the small size of the trial it is based upon and therefore our results are uncertain. Further research would be of high value, particularly with respect to the quality of life gain achieved by people who respond well to therapy.
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Mitchell, A. L., A. Gandhi, D. Scott-Coombes, and P. Perros. "Management of thyroid cancer: United Kingdom National Multidisciplinary Guidelines." Journal of Laryngology & Otology 130, S2 (May 2016): S150—S160. http://dx.doi.org/10.1017/s0022215116000578.
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AbstractThis is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. This paper provides recommendations on the management of thyroid cancer in adults and is based on the 2014 British Thyroid Association guidelines.Recommendations• Ultrasound scanning (USS) of the nodule or goitre is a crucial investigation in guiding the need for fine needle aspiration cytology (FNAC). (R)• FNAC should be considered for all nodules with suspicious ultrasound features (U3–U5). If a nodule is smaller than 10 mm in diameter, USS guided FNAC is not recommended unless clinically suspicious lymph nodes on USS are also present. (R)• Cytological analysis and categorisation should be reported according to the current British Thyroid Association Guidance. (R)• Ultrasound scanning assessment of cervical nodes should be done in FNAC-proven cancer. (R)• Magnetic resonance imaging (MRI) or computed tomography (CT) should be done in suspected cases of retrosternal extension, fixed tumours (local invasion with or without vocal cord paralysis) or when haemoptysis is reported. When CT with contrast is used pre-operatively, there should be a two-month delay between the use of iodinated contrast media and subsequent radioactive iodine (I131) therapy. (R)• Fluoro-deoxy-glucose positron emission tomography imaging is not recommended for routine evaluation. (G)• In patients with thyroid cancer, assessment of extrathyroidal extension and lymph node disease in the central and lateral neck compartments should be undertaken pre-operatively by USS and cross-sectional imaging (CT or MRI) if indicated. (R)• For patients with Thy 3f or Thy 4 FNAC a diagnostic hemithyroidectomy is recommended. (R)• Total thyroidectomy is recommended for patients with tumours greater than 4 cm in diameter or tumours of any size in association with any of the following characteristics: multifocal disease, bilateral disease, extrathyroidal spread (pT3 and pT4a), familial disease and those with clinically or radiologically involved nodes and/or distant metastases. (R)• Subtotal thyroidectomy should not be used in the management of thyroid cancer. (G)• Central compartment neck dissection is not routinely recommended for patients with papillary thyroid cancer without clinical or radiological evidence of lymph node involvement, provided they meet all of the following criteria: classical type papillary thyroid cancer, patient less than 45 years old, unifocal tumour, less than 4 cm, no extrathyroidal extension on ultrasound. (R)• Patients with metastases in the lateral compartment should undergo therapeutic lateral and central compartment neck dissection. (R)• Patients with follicular cancer with greater than 4 cm tumours should be treated with total thyroidectomy. (R)• I131 ablation should be carried out only in centres with appropriate facilities. (R)• Serum thyroglobulin (Tg) should be checked in all post-operative patients with differentiated thyroid cancer (DTC), but not sooner than six weeks after surgery. (R)• Patients who have undergone total or near total thyroidectomy should be started on levothyroxine 2 µg per kg or liothyronine 20 mcg tds after surgery. (R)• The majority of patients with a tumour more than 1 cm in diameter, who have undergone total or near-total thyroidectomy, should have I131 ablation. (R)• A post-ablation scan should be performed 3–10 days after I131 ablation. (R)• Post-therapy dynamic risk stratification at 9–12 months is used to guide further management. (G)• Potentially resectable recurrent or persistent disease should be managed with surgery whenever possible. (R)• Distant metastases and sites not amenable to surgery which are iodine avid should be treated with I131 therapy. (R)• Long-term follow-up for patients with differentiated thyroid cancer (DTC) is recommended. (G)• Follow-up should be based on clinical examination, serum Tg and thyroid-stimulating hormone assessments. (R)• Patients with suspected medullary thyroid cancer (MTC) should be investigated with calcitonin and carcino-embryonic antigen levels (CEA), 24 hour catecholamine and nor metanephrine urine estimation (or plasma free nor metanephrine estimation), serum calcium and parathyroid hormone. (R)• Relevant imaging studies are advisable to guide the extent of surgery. (R)• RET (Proto-oncogene tyrosine-protein kinase receptor) proto-oncogene analysis should be performed after surgery. (R)• All patients with known or suspected MTC should have serum calcitonin and biochemical screening for phaeochromocytoma pre-operatively. (R)• All patients with proven MTC greater than 5 mm should undergo total thyroidectomy and central compartment neck dissection. (R)• Patients with MTC with lateral nodal involvement should undergo selective neck dissection (IIa–Vb). (R)• Patients with MTC with central node metastases should undergo ipsilateral prophylactic lateral node dissection. (R)• Prophylactic thyroidectomy should be offered to RET-positive family members. (R)• All patients with proven MTC should have genetic screening. (R)• Radiotherapy may be useful in controlling local symptoms in patients with inoperable disease. (R)• Chemotherapy with tyrosine kinase inhibitors may help in controlling local symptoms. (R)• For individuals with anaplastic thyroid carcinoma, initial assessment should focus on identifying the small proportion of patients with localised disease and good performance status, which may benefit from surgical resection and other adjuvant therapies. (G)• The surgical intent should be gross tumour resection and not merely an attempt at debulking. (G)
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Yarbrough, Courtney R. "Plan generosity in health insurance exchanges: what the Affordable Care Act can teach us about top-down versus bottom-up policy implementation." Journal of Public Policy 37, no. 1 (February 23, 2016): 55–83. http://dx.doi.org/10.1017/s0143814x16000015.
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AbstractThe landmark United States healthcare reform law – the Affordable Care Act – provides an opportunity to study the dynamics of implementation for complex, politically contentious policies. Matland’s Ambiguity-Conflict Model suggests that bottom-up models will dominate in such cases. I exploit variation across states in the implementation of online health insurance marketplaces to test whether the federal- (top-down) or state-managed (bottom-up) implementation model produced better outcomes. Specifically, the study examines if state, federal or partnership exchanges were most effective at offering generous plans for consumers based on premiums, deductibles and copayments in 2014, the first year of operation. The results unambiguously indicate that state exchanges were most successful. The findings provide evidence for what Matland suspected – that bottom-up models, by providing more discretion to local implementers to adapt to contexts and build coalitions, are superior for high-conflict, high-ambiguity policies.
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Jeurissen, Patrick P. T., Florien M. Kruse, Reinhard Busse, David U. Himmelstein, Elias Mossialos, and Steffie Woolhandler. "For-Profit Hospitals Have Thrived Because of Generous Public Reimbursement Schemes, Not Greater Efficiency: A Multi-Country Case Study." International Journal of Health Services 51, no. 1 (October 27, 2020): 67–89. http://dx.doi.org/10.1177/0020731420966976.
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For-profit hospitals’ market share has increased in many nations over recent decades. Previous studies suggest that their growth is not attributable to superior performance on access, quality of care, or efficiency. We analyzed other factors that we hypothesized may contribute to the increasing role of for-profit hospitals. We studied the historical development of the for-profit hospital sector across 4 nations with contrasting trends in for-profit hospital market share: the United States, the United Kingdom, Germany, and the Netherlands. We focused on 3 factors that we believed might help explain why the role of for-profits grew in some nations but not in others: (1) the treatment of for-profits by public reimbursement plans, (2) physicians’ financial interests, and (3) the effect of the political environment. We conclude that access to subsidies and reimbursement under favorable terms from public health care payors is an important factor in the rise of for-profit hospitals. Arrangements that aligned financial incentives of physicians with the interests of for-profit hospitals were important in stimulating for-profit growth in an earlier era, but they play little role at present. Remarkably, the environment for for-profit ownership seems to have been largely immune to political shifts.
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Liepa, Astra M., Jacqueline Brown, Bela Bapat, and James A. Kaye. "Real-world treatment patterns of previously treated advanced gastric and gastroesophageal junction adenocarcinoma (GC) in the United Kingdom (UK)." Journal of Clinical Oncology 33, no. 3_suppl (January 20, 2015): 184. http://dx.doi.org/10.1200/jco.2015.33.3_suppl.184.
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184 Background: With no licensed therapies for previously treated advanced GC, little is known on how patients (pts) are managed after 1st-line chemotherapy (CTx) has failed. We present real-world data on characteristics, treatments, and resource utilization (RU) for such pts in the UK. Methods: Physicians who treat pts with advanced GC completed a web-based chart review detailing clinical and RU data for 3-4 de-identified pts each. Eligible pts were ≥18 years old, diagnosed Jan 2007-Mar 2012 with advanced GC, received 1st-line fluoropyrimidine+platinum, and had ≥3 months of follow-up after 1st-line discontinuation (DC). Data were summarized descriptively. Results: From Jun to Jul 2013, 58 physicians provided data for 200 pts. Pts’ mean age was 61 years; 69.5% were male. At advanced stage diagnosis, ECOG performance status (PS) was 21% 0, 72.5% 1, and 6.5% 2. The most common 1st-line regimens were capecitabine (cape)+oxaliplatin+epirubicin (epi) (34%), cape+cisplatin+epi (20.5%) and 5-FU+cisplatin+epi (13%). The most common reasons for 1st-line DC were completion of planned regimen (63%) and disease progression (24%). ECOG PS at 1st-line DC was 5% 0, 57.5% 1, 32% 2, 5.5% 3. 28.5% received 2nd-line, and 79% of these had PS 0/1 at start of 2nd-line. 21 unique 2nd-line regimens were reported; most common were docetaxel (28%), paclitaxel (11%), trastuzumab (9%), cape (7%) and irinotecan (7%). Among pts who received 2nd-line, 5% received 3rd-line. (See table.) The most common contributing reasons for hospitalization were palliative care and disease progression. Conclusions: In our study sample of advanced GC, the minority of pts received subsequent CTx after 1st-line CTx. There was considerable variation in 2nd-line regimens, although primarily monotherapy. Pts who received 2nd-line CTx had numerically similar or lower rates of supportive care. [Table: see text]
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Olsson-Brown, Anna Claire, Mark Baxter, Caroline Dobeson, Laura Feeney, Rebecca Lee, Alec Maynard, Shagufta Mirza, et al. "Real-world outcomes in older adults treated with immunotherapy: A United Kingdom multicenter series of 2,049 patients." Journal of Clinical Oncology 39, no. 15_suppl (May 20, 2021): 12026. http://dx.doi.org/10.1200/jco.2021.39.15_suppl.12026.
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12026 Background: Immune checkpoint inhibitor (ICI) therapy is now commonly used in a range of tumours and settings. Most data relating to outcomes and rates of immune-related adverse events (irAE) is derived from clinical trial or registry populations and small case series. Limited data exist for patients aged > 75 years. Here we present a multi-centre, real-world analysis of the outcomes and incidence of irAEs in older adults managed within a single comprehensive public health service. We also compare these outcomes to younger patients in the same cohort. Methods: A retrospective analysis of 2049 patients treated with ICIs was undertaken across 12 centres. All patients were managed within the UK National Health Service outside of a trial setting between June 2016 and September 2018. Patients received either ICI monotherapy (MT) or duel combination ICI therapy (CT) for malignant melanoma (MM), non-small cell lung cancer (NSCLC) or renal cell cancer (RCC). Data were collected using a standardised, collection tool. IrAEs ≥ grade 2 or all-grade endocrinopathies were recorded as per the Common Terminology Criteria for Adverse Events (V5) (CTCAE). Statistical analyses were performed using T-tests, Mann-Whitney and Chi-squared. Kaplan-Meier analysis and log-rank test were used for overall survival (OS) analysis. Results: 409 (20%) of patients were aged > 75 years(a), 1413 (69%) aged 50-75(b) and 227 (11.1%) aged < 50(c). There was no difference in sex, ethnicity or PD-L1 status (in the NSCLC cohort) between groups. Older patients were less likely to receive combination therapy (3%(a) v 13%(b) v 34%(c), p < 0.001). There was no difference in median OS across age groups in the cohort as a whole (p = 0.822) or for the individual tumour groups when treated with single agent ICI. Across the total cohort patients aged > 75 had no increased risk of any irAE (35%(a) v 33%(b) v 41%(c),p = 0.074). However there was an increase in irAEs in older patients treated with MT (36%(a) v 26(b) v 25%(c), p = 0.011) However there was no difference in the > 75s with regard to severe (G3/4) toxicity, toxicity type, admission or discontinuation due to toxicity in the aPD-1 group. In the overall cohort younger patients were more likely to develop irAEs and be admitted. Conclusions: Patients aged > 75 years treated with anti-PD1 therapy in the standard of care setting derive similar survival benefit to younger patients. There was no increase in ≥G3 toxicity. Our data support the safety of single agent aPD-1 ICI therapy in older adults and provide reassurance relating to the impact of toxicity.[Table: see text]
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Wallace, Katrine, Adrienne Landsteiner, Scott Bunner, Nicole Engel-Nitz, and Amy Luckenbaugh. "Epidemiology and mortality of metastatic castration-resistant prostate cancer (mCRPC) in a managed care population in the United States." Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020): e13592-e13592. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.e13592.
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e13592 Background: To date, there has been a paucity of information in the literature describing the epidemiology of mCRPC within the prostate cancer population. We present a real-world data study describing characteristics and mortality of patients with mCRPC within an administrative claims database of an insured population within the United States. Methods: In an administrative claims database of ≈18,000,000 covered lives, adult male patients were included if they had ≥1 claim for prostate cancer (ICD-9: 185 or 233.4; ICD-10: C61 or D075), underwent pharmacologic or surgical castration, and had a code for metastatic disease during the identification period (January 1, 2008–March 31, 2018). The index date was the first metastatic claim; 6 months of continuous enrollment (CE) prior to (baseline period) and after (follow-up period) the index date was required. Patients with metastatic claims in the baseline period were excluded. Patients were followed until the earliest of: death (unless prior to the 6-month CE), end of study period, or disenrollment. A claims-based algorithm was employed to identify locally advanced and distant mCRPC patients in the prostate cancer study population. Mortality data were sourced from the Social Security Administration Medicare data, and a claims algorithm. Results: 343,089 patients were identified with a claim for prostate cancer; of those, 3690 mCRPC cases (1.1%) were identified using the claims-based algorithm and met the study inclusion criteria. Median age was 75 years. Insurance type included commercial plans (27%) and Medicare (73%). Castration type included pharmacologic (99%) and surgical (1%). First claims for metastases were most commonly in the bone (65%) or lymph nodes (15%), with 20% in other sites. The study population averaged a Charlson comorbidity index score of 3.05 at baseline, with 16% of patients receiving a score of ≥5. The most common baseline comorbidities were hypertension (67%), urinary disease (58%), dyslipidemia (52%), and cardiac disease (45%). Median follow-up time among the mCRPC group was 538 days, during which 1834 deaths occurred; 50% of the population experienced mortality during the study period. Conclusions: This study provides valuable insights into the epidemiology, clinical characteristics, prevalence rate, and mortality of patients with mCRPC. Given the high mortality proportion of this disease, the development of novel therapies to prolong life in patients with mCRPC is warranted.
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DAVIS, JOHN B. "Will Social Values Influence the Development of HMOs?" Cambridge Quarterly of Healthcare Ethics 11, no. 4 (August 30, 2002): 418–21. http://dx.doi.org/10.1017/s0963180102004176.
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Among industrialized nations the United States is relatively unique in relying on a mix of public and private financing and delivery of healthcare: federal and federal-state programs, such as Medicare and Medicaid; employment-based health insurance (primarily HMOs); and state-subsidized insurance pools for high-risk individuals. In recent years, however, there have been efforts to apply the principles of private employment-based health insurance to the other forms of healthcare, and there is speculation that rising healthcare costs can only be addressed by further extending capitated payment plans. This suggests that U.S. healthcare may increasingly be organized according to market principles. For some, this represents a historic departure from an emphasis on public responsibility for healthcare and a sacrifice of the value principles embodied in health relationships between patient and provider. But defenders of HMOs and a larger role for markets argue that managed care allows for a more rational allocation of scarce healthcare resources by minimizing inefficient low-benefit–high-cost care. More individuals receive essential care if inessential care is eliminated. HMOs are also said to encourage non-HMOs to provide lower priced healthcare.