P2650Antihypertensive treatment with calcium channel blockers in patients with moderate or severe aortic stenosis: relationship with all-cause mortality

Background

Hypertension is prevalent in patients with aortic stenosis (AS) and optimal blood pressure (BP) control is advised to reduce arterial load and avoid cardiovascular events. Whether calcium channel blockers (CCB) are safe is not known.

Methods

A total of 314 patients (age 65±12 y, 68% men) with moderate or severe asymptomatic AS were included.

Results

The prevalence of hypertension was 73.6%, and 65% took antihypertensive treatment. Patients who used a CCB (25%) (CCB+) were older, had higher clinic systolic BP, were more likely to have hypercholesterolemia and coronary artery disease (CAD), and to use a diuretic or alpha blocker compared to CCB- patients (all p<0.05) (Table). During the baseline ETT, patients who used a CCB achieved a lower peak heart rate, a shorter exercise time and were more likely to have a blunted BP response compared to those who did not use a CCB (all p<0.05) (Table). Event-free survival was significantly lower in CCB+ than CCB- patients (Fig) (all-cause mortality 16 [20.3%] versus 13 (5.6%); p<0.001). In a multivariable Cox regression model, CCB+ was associated with a 6.8-fold increased hazard ratio (HR) for all-cause mortality (HR 6.77 95% CI 1.66–27.54, p=0.008), independent of age, gender, systolic BP, hypertension, diabetes, CAD, hypercholesterolemia and aortic valve area.

Table 1. Baseline characteristics of patients CCB− (n=234) CCB+ (n=80) p Age, y 64±12 70±10 <0.001 CAD, % 45 66 0.006 Hypercholesterolemia, % 62 78 0.015 Clinic systolic BP, mmHg 139±19 150±17 <0.001 Left atrial diameter, cm 3.7±0.7 3.9±0.6 0.007 LV end-diastolic diameter, cm 4.5±0.7 4.8±0.6 0.002 LV mass index, g/m2.7 50±17 57±17 0.007 Aortic valve area, cm2 0.94±0.22 0.93±0.22 0.716 LV stroke work, g-m/bmp 155±46 175±69 0.046 Peak HR at baseline ETT, bmp 138±24 120±25 <0.001 Blunted BP response, % 33 49 0.013 Exercise duration, min 10.1±4.5 8.3±3.7 0.001 Double Product, mmHg·bmp 1.85±0.43 2.08±0.54 <0.001

Figure 1

Conclusion

The use of calcium channel blockers was associated with an adverse effect on treadmill exercise and reduced survival in apparently asymptomatic patients with moderate or severe AS.

Acknowledgement/Funding

None

Development of a National Cancer Registry in a Low Resourced Country: The Case of Kenya National Cancer Registry Programme

Background: Population-based cancer registration represents the gold standard for the provision of information on cancer incidence in a defined population (Bray F, et. al, IARC Technical Report No. 43). In Kenya, the incidence and prevalence of cancer has not been well documented. The existing population-based cancer registries (PBCRs) cover less than 10% of Kenya's population. Kenya is made up of 47 administrative counties and has a population of over 45 million people. Aim: To establish a National Cancer Registry Program that will compile national data on incidence, mortality and trends of cancer in Kenya over time. Methods: Three functional PBCRs have been in existence covering 3 counties: Nairobi, Eldoret and Kisumu. Needs assessment was conducted in the 3 registries. Additional support and resources were provided. New registries were set up in different geographical regions of Kenya. A centralized office to host the national registry was established and equipped at the Centre for Clinical Research, Kenya Medical Research Institute. Sensitization and awareness activities targeting the leaders in the selected counties were undertaken. Similarly trainings and technical support of the regional registries were conducted. Data were collected on to case registration forms, coded using the International Classification of Diseases for Oncology (ICD-O); data entry, validation and analysis done using IARC software CanReg5. Results: Variations in cancer occurrence in the different counties were noted. However the leading cancers were somewhat similar in the 8 counties with prostate and esophageal cancers being the leading in men while breast and cervical cancer being top among women. These variations could provide understanding on causation of certain types of cancers. Data highlights the need to develop and expand intervention programs like HPV vaccination, screenings, early detection and early treatment. Governments' allocation of resources to cancer registries and surveillance programs is important as well as building partnerships. Conclusion: In countries with limited resources it is expensive to develop a national cancer registry covering the entire country. Our program demonstrates that a national cancer registry program can be established by setting up regional population-based cancer registries that covers a reasonable population of the entire country and aggregating the data in a centralized system. Population-based cancer registries are critical in generating data on burden of cancer in specified populations. These data should be used to inform effective cancer control programs and research.

Lessons learned about prevalence and growth rates of abdominal aortic aneurysms from a 25-year ultrasound population screening programme

Background

This study aimed to assess how the prevalence and growth rates of small and medium abdominal aortic aneurysms (AAAs) (3·0–5·4 cm) have changed over time in men aged 65 years, and to evaluate long-term outcomes in men whose aortic diameter is 2·6–2·9 cm (subaneurysmal), and below the standard threshold for most surveillance programmes.

Methods

The Gloucestershire Aneurysm Screening Programme (GASP) started in 1990. Men aged 65 years with an aortic diameter of 2·6–5·4 cm, measured by ultrasonography using the inner to inner wall method, were included in surveillance. Aortic diameter growth rates were estimated separately for men who initially had a subaneurysmal aorta, and those who had a small or medium AAA, using mixed-effects models.

Results

Since 1990, 81 150 men had ultrasound screening for AAA (uptake 80·7 per cent), of whom 2795 had an aortic diameter of 2·6–5·4 cm. The prevalence of screen-detected AAA of 3·0 cm or larger decreased from 5·0 per cent in 1991 to 1·3 per cent in 2015. There was no evidence of a change in AAA growth rates during this time. Of men who initially had a subaneurysmal aorta, 57·6 (95 per cent c.i. 54·4 to 60·7) per cent were estimated to develop an AAA of 3·0 cm or larger within 5 years of the initial scan, and 28·0 (24·2 to 31·8) per cent to develop a large AAA (at least 5·5 cm) within 15 years.

Conclusion

The prevalence of screen-detected small and medium AAAs has decreased over the past 25 years, but growth rates have remained similar. Men with a subaneurysmal aorta at age 65 years have a substantial risk of developing a large AAA by the age of 80 years.

Medium-term cost-effectiveness of an automated non-invasive ventilation outpatient set-up versus a standard fixed level non-invasive ventilation inpatient set-up in obese patients with chronic respiratory failure: a protocol description

INTRODUCTION

Obesity is an escalating issue, with an accompanying increase in referrals of patients with obesity-related respiratory failure. Currently, these patients are electively admitted to hospital for initiation of non-invasive ventilation (NIV), but it is unknown whether outpatient initiation is as effective as inpatient set-up. We hypothesise that outpatient set-up using an autotitrating NIV device will be more cost-effective than a nurse-led inpatient titration and set-up.

METHODS AND ANALYSIS

We will undertake a multinational, multicentre randomised controlled trial. Participants will be randomised to receive the usual inpatient set-up, which will include nurse-led initiation of NIV or outpatient set-up with an automated NIV device. They will be stratified according to the trial site, gender and previous use of NIV or continuous positive airway pressure. Assuming a 10% dropout rate, a total sample of 82 patients will be required. Cost-effectiveness will be evaluated using standard treatment costs and health service utilisation as well as health-related quality of life measures (severe respiratory insufficiency (SRI) and EuroQol-5 dimensions (EQ-5D)). A change in the SRI questionnaire will be based on the analysis of covariance adjusting for the baseline measurements between the two arms of patients.

ETHICS AND DISSEMINATION

This study has been approved by the Westminster National Research Ethics Committee (11/LO/0414) and is the trial registered on the UKCRN portfolio. The trial is planned to start in January 2015 with publication of the trial results in 2017.

TRIAL REGISTRATION NUMBER

ISRCTN 51420481.

Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L)

Purpose

This article introduces the new 5-level EQ-5D (EQ-5D-5L) health status measure.

Methods

EQ-5D currently measures health using three levels of severity in five dimensions. A EuroQol Group task force was established to find ways of improving the instrument’s sensitivity and reducing ceiling effects by increasing the number of severity levels. The study was performed in the United Kingdom and Spain. Severity labels for 5 levels in each dimension were identified using response scaling. Focus groups were used to investigate the face and content validity of the new versions, including hypothetical health states generated from those versions.

Results

Selecting labels at approximately the 25th, 50th, and 75th centiles produced two alternative 5-level versions. Focus group work showed a slight preference for the wording ‘slight-moderate-severe’ problems, with anchors of ‘no problems’ and ‘unable to do’ in the EQ-5D functional dimensions. Similar wording was used in the Pain/Discomfort and Anxiety/Depression dimensions. Hypothetical health states were well understood though participants stressed the need for the internal coherence of health states.

Conclusions

A 5-level version of the EQ-5D has been developed by the EuroQol Group. Further testing is required to determine whether the new version improves sensitivity and reduces ceiling effects.

Randomized clinical trial of different bandage regimens after foam sclerotherapy for varicose veins

BACKGROUND

This trial compared outcomes after foam sclerotherapy in patients wearing compression bandaging for 24 h or 5 days after treatment.

METHODS

Consecutive patients with primary uncomplicated varicose veins were randomized after foam sclerotherapy treatment. The primary endpoint was 6-week Aberdeen Varicose Vein Severity Score (AVVSS) and Burford pain score.

RESULTS

Some 124 legs were randomized, 61 to 24 h and 63 to 5 days of bandaging. Target vein occlusion rates at 6-week duplex imaging were 90 and 89 per cent respectively (P = 0.842). There was no significant difference in phlebitis after 2 weeks (P = 0.445) or skin discoloration after 6 weeks (46 versus 40 per cent; P = 0.546). There was no significant difference in the change in AVVSS from baseline to 2 weeks (-0.29 versus -0.80; P = 0.717) or to 6 weeks (-5.89 versus -5.14; 95 per cent confidence interval (c.i.) for the difference -3.29 to 1.80; P = 0.563), or in change in Burford pain score from baseline to 2 weeks (-9.04 versus -2.80; P = 0.248) or to 6 weeks (-17.32 versus -8.46; 95 per cent c.i. for the difference -19.06 to 1.33; P = 0.088), or in change in Short Form 36 score from baseline to 6 weeks (2.02 versus 1.74; P = 0.903).

CONCLUSION

There was no advantage to compression bandaging for more than 24 h when thromboembolus deterrent stockings were worn for the remainder of 14 days.

REGISTRATION NUMBER

NCT00991497 (http://www.clinicaltrials.gov).

A review of the evidence for the impact of improving nutritional care on nutritional and clinical outcomes and cost

BACKGROUND

The association between malnutrition and poor clinical outcome is well-established, yet most research has focussed on the role of artificial nutritional support in its management. More recently, emphasis has been placed on the provision of adequate nutritional care, including nutritional screening and the routine provision of food and drink. The aim of this literature review is to establish the evidence for the efficacy of interventions that might result in improvements in nutritional and clinical outcomes and costs.

METHODS

A structured literature review was conducted investigating the role of nutritional care interventions in adults, and their effects on nutritional and clinical outcomes and costs, in all healthcare settings. Ten databases were searched electronically using keywords relating to nutritional care, patient outcomes and healthcare costs. High quality trials were included where available.

RESULTS

Two hundred and ninety-seven papers were identified and reviewed. Of these, only two randomised, controlled trials and six other trials were identified that addressed the major issues. A further 99 addressed some aspects of the provision of nutritional care, although very few formally evaluated nutritional or clinical outcomes and costs.

CONCLUSIONS

This review reveals a serious lack of evidence to support interventions designed to improve nutritional care, in particular with reference to their effects on nutritional and clinical outcomes and costs. The review suggests that screening alone may be insufficient to achieve beneficial effects and thus more research is required to determine the most cost-effective interventions in each part of the nutritional care pathway, in a variety of healthcare settings and across all age ranges, to impact upon nutritional and clinical outcomes.

A phase II study of the feasibility of sequential carboplatin (C) followed by paclitaxel (P) and gemcitabine (G) as first-line chemotherapy for stage Ic-IV ovarian (OC), fallopian tube (FTC), and primary peritoneal carcinoma (PPC)

5578

Background: We previously explored the feasibility of adding G to C + P in a phase II study, in which 4 cycles of C followed by 4 cycles of concurrent weekly P and G were given (BJC (2004) 91:627–32). Although highly active (med PFS 19.5m), the feasibility of this 1st-line regimen was limited by dyspnea during the weekly P+G phase. The current trial assessed whether the dyspnoea could be ameliorated by altering the schedule. Methods: Untreated FIGO stage Ic-IV OC, FTC and PPC patients (pts) were eligible. Chemotherapy (CTX) consisted of 4 cycles of C (AUC 7) q21 days, followed by 4 cycles of concurrent P (175 mg/m2) d1 and G (1,000 mg/m2) d1 and d8 q21 days. The primary endpoint of the study was the percentage of pts completing the planned 8 cycles of CTX. The planned sample size was 54 pts, based on a one stage single arm study design with 95% power to reject the null hypothesis (completion rate less than 60%), assuming a true completion rate of 80% using one-sided alpha=0.05. Results: All 54 pts were recruited between June 05 and June 06. Details for 44 pts are currently available for the C phase. 38% of these pts had one or more dose reduction (DR), and 68% had dose delays (DD). The commonest reason for DR and DD was neutropenia. Details for 33 pts are currently available for the P+G phase. 27% of these pts had a DR of P and 51% had a DR of G. 71% of pts omitted G on D8, and 64% had a DD. The commonest reasons for DR and DD were neutropenia and thrombocytopenia. Overall, the KM estimate of the percentage completing 8 cycles is 75% (95% CI 61%-89%) based on the current data. Dyspnoea (Grade 2 only) was observed in 4.5% and 3% pts during the C and P+G phases respectively. No significant treatment related CXR changes were observed. The overall response rate was 68% (95% CI 45–86%; 36% CR, 32%PR, 14% SD, 5%PD, 14% NE; n=22). The median follow-up is 7.5 months and the PFS at 8 months is 92% (95% CI 77–97%). Conclusion: This schedule appears to ameliorate the previously observed dyspnoea, while retaining comparable efficacy. The feasibility of this regimen is limited by myelosuppression which could potentially be overcome by: a) reducing the dose of gemcitabine to 750 mg/m2, or b) using prophylactic Peg-GCSF.

[Table: see text]

SCOTROC 2A: carboplatin followed by docetaxel or docetaxel-gemcitabine as first-line chemotherapy for ovarian cancer

The feasibility of sequential carboplatin followed by docetaxel-based therapy for untreated ovarian cancer was determined. Patients received four q3w cycles of carboplatin AUC 7, then four q3w cycles of either docetaxel 100 mg m(-2) (day 1) (arm A); docetaxel 75 mg m(-2) (day 8) and gemcitabine 1250 mg m(-2) (days 1,8) (arm B) or docetaxel 25 mg m(-2) and gemcitabine 800 mg m(-2) (both given weekly (days 1,8,15)) (arm C). A total of 44 patients were randomised to each treatment arm. None of the arms demonstrated an eight cycle completion rate (70.5/72.7/45.5% in arms A/B/C, respectively), which was statistically greater than 60% (P=0.102, P=0.056, P=0.982) which was our formal feasibility criteria, although only the completion rate in arm C was clearly worse than this level. The overall response rate (ORR) after carboplatin was 65.7% in 70 evaluable patients. In evaluable patients, ORRs after docetaxel-based cycles were: arm A 84.0% (21 out of 25); arm B 77.3% (17 out of 22); arm C 69.6% (16 out of 23). At follow-up (median 30 months), median progression-free survival times were: arm A 15.5 months (95% CI: 10.5-20.6); arm B 18.1 months (95% CI: 15.9-20.3); arm C, 13.7 months (95% CI: 12.8-14.6). Neutropenia was the predominant grade 3-4 haematological toxicity: 77.8/85.7/54.4% in arms A/B/C, respectively. Dyspnoea was markedly increased in both gemcitabine-containing arms (P=0.001) but was worse in arm C. Although just failing to rule out eight cycle completion rates less than 60%, within the statistical limitations of these small cohorts, the overall results for arms A and B are encouraging. Larger phase III studies are required to test these combinations.

A randomised comparison of treosulfan and carboplatin in patients with ovarian cancer: a study by the Scottish Gynaecological Cancer Trials Group (SGCTG)

The management of older and unfit women with advanced ovarian cancer requires post-operative chemotherapy but many of these patients are not suitable for high-dose cisplatin-based regimes. Carboplatin has been an easier alternative and can be given in the ambulatory setting. Historical data suggests that oral alkylating agents to be just effective with similar efficacy. In this study we have compared platinum-based carboplatin to the alkylating agent treosulfan in a population unfit to receive high-dose cisplatin. The trial randomised patients to either intravenous carboplatin or treosulfan as single agent. The trial was stopped prematurely after the interim analysis showed improved survival and response rates in the carboplatin arm. We conclude that carboplatin is a safe and effective drug in a population that is unfit for high-dose cisplatin. Treosulfan showed limited activity but may be considered along with other oral drugs in limited circumstances. With the exception of myelosuppression, toxicity was mild in both arms. Carboplatin remains the gold standard in this older and less fit group of patients.

Abnormal serum lipoprotein levels as a risk factor for the development of human lenticular opacities

AIM

To determine whether an association exists between the different plasma lipoprotein constituents and the prevalence of lenticular opacities in dyslipidaemic subjects.

METHODS

Adult patients (n = 115) of both genders were included if their fasting total serum cholesterol concentrations exceeded the 95th percentile of normal or their serum low-density lipoprotein (LDL): high-density lipoprotein (HDL) ratios exceeded 5. Patients were excluded if they suffered from any condition known to cause, or predispose them to, elevated lipoprotein levels or lenticular opacification. Lenticular changes were assessed by means of a slit-lamp through the fully dilated pupil.

RESULTS

An extremely strong association (p<0.0001) was found to exist between HDL cholesterol levels and the development of lens opacities. Below an HDL-C level of 1.5 mmol/l subjects had a seven-fold higher calculated probability of falling in the lens opacity subgroup than those with HDL-C levels above 1.5 mmol/l [odds ratio =7.33 (95% CI = 2.06-26.10; p = 0.0001)]. An equally strong association was found between high (>5) LDL:HDL ratios and the development of lens opacities (p<0.0003). The risk of falling into the cataract subgroup if the individual's LDL:HDL ratio exceeded 5 was 2.35 (95% CI = 1.09-5.04; p = 0.014).

CONCLUSION

This study strongly suggests that an association exists between low levels of HDL cholesterol and high LDL:HDL ratios on one hand and the development of adult lens opacification on the other.

A case of B-cell lymphoblastic lymphoma involving the uterus

A 59-year-old postmenopausal woman presented with vaginal bleeding, lower abdominal pain, severe anaemia, leucocytosis, and an ultrasonographic finding of a large mass arising within the pelvis, most likely ovarian in origin. The patient was taken to the operating theatre with the possible diagnosis of acute haemorrhage into an ovarian cyst. At laparotomy there was a large mass at the posterior uterine wall extending retroperitoneally into the left pelvic side-wall. There was also significant paraaortic lymphadenopathy. The tumor was not resectable and biopsies were taken for pathological examination which showed a precursor B cell lymphoblastic lymphoma. Although the existence of lymphomas involving the uterus is well documented, the presentation of the lymphoma in this case was very unusual and this is the first reported case of a confirmed precursor B-cell lymphoblastic lymphoma involving the uterus.

Renal flares are common in patients with severe proliferative lupus nephritis treated with pulse immunosuppressive therapy: long-term followup of a cohort of 145 patients participating in randomized controlled studies

OBJECTIVE

Immunosuppressive agents have become the standard of therapy for proliferative lupus nephritis, but some patients may relapse after discontinuing treatment. We reviewed the cases of renal flares in a cohort of patients who participated in 2 randomized controlled clinical trials at the National Institutes of Health and explored the prevalence, outcome, and predictive factors of renal flares.

METHODS

Data were obtained on 145 patients treated with pulse cyclophosphamide, pulse methylprednisolone, or the combination of both. Patients had not received immunosuppressive therapy for at least 6 months and had experienced complete or partial response according to defined criteria. Renal flares were classified as either proteinuric or nephritic based on changes in urinary protein and sediment. Most patients who experienced a flare received additional immunosuppressive therapy.

RESULTS

Seventy-three patients had a complete response, and 19 had partial response/stabilization. Forty-one of these patients (45%) experienced renal flares (nephritic in 33, proteinuric in 8) after a mean followup of 117 months; 31 of them received additional immunosuppressive therapy. The median time to renal flare was 36 months in the complete responders and 18 months in the partial responders. Eleven of the 41 patients (27%) progressed to end-stage renal disease (ESRD); 9 had nephritic flares (all severe except for 1) and 2 had proteinuric flares (1 in each responder group). Compared with patients who had a complete response, those with a partial response were more likely to experience a flare, to have a severe nephritic flare, or to progress to ESRD. Low C4 at the time of response and African American ethnicity were significant independent risk factors for renal flare, by multivariate Cox proportional hazards analysis.

CONCLUSION

Nephritic flares are common in patients with proliferative lupus nephritis, even in those with a complete response to therapy, but they do not necessarily result in loss of renal function if treated with additional immunosuppressive agents. Renal flares are an important feature of the natural history of lupus nephritis and provide an opportunity for additional preventive strategies, as well as measures of efficacy in future therapeutic trials.

Direct NO group transfer from S-nitrosothiols to iron centres

A number of S-nitrosothiols react rapidly with the Fe(II) complexes of 2,3-dimercapto-1-propanesulfonic acid (DMPS) and of N-methyl-D-glucamine dithiocarbamate (MGD), transferring the NO group directly to the iron centres.

Cytochrome P450 CYP1B1 over-expression in primary and metastatic ovarian cancer

Ovarian cancer is the most frequent cause of death from gynaecological malignancies world wide. Little improvement has been made in the long-term outcome of this disease, with the 5-year survival of patients only 30%. This poor prognosis is due to the late presentation of the disease and to the unpredictable response of ovarian cancer to chemotherapy. The cytochrome P450 enzymes are a superfamily of haemoproteins, known to be involved in the metabolic activation and/or detoxification of a number of anti-cancer drugs. CYP1B1 is a tumour-related form of cytochrome P450 which is over expressed in a wide variety of primary tumours of different histological type. The presence of CYP1B1 may be of importance in the modulation of these tumours to anti-cancer drugs. We have conducted a comprehensive immunohistochemical investigation, into the presence of cytochrome P450 CYP1B1 in primary and metastatic ovarian cancer. The key findings of this study are the increased expression of CYP1B1 in the majority of ovarian cancers investigated (92%), with a strong correlation demonstrated between CYP1B1 expression in both primary and metastatic ovarian cancer (P = 0.005 Spearman's rank correlation test). In contrast no detectable CYP1B1 was found in normal ovary.

How patients with atrial fibrillation value different health outcomes: a standard gamble study

BACKGROUND AND PURPOSE

The assessment of any health care intervention should consider both risks and benefits and take patients' preferences about these into account. The study reported in this paper aimed to elicit patient valuations of health states relevant to assessment of the prevention of stroke by warfarin anticoagulation therapy for patients with atrial fibrillation.

METHODS

A sample of patients over the age of 60 years with atrial fibrillation from three family practices in North-East England was interviewed. Their health state values were elicited using the standard gamble method for general practitioner (GP)-managed warfarin treatment, hospital-managed warfarin treatment, major bleed, mild stroke and severe stroke.

RESULTS

Of 180 patients, 69 (38%) agreed to participate, of whom 57 (83%) completed interviews. Median (mean) utility values were for GP-managed warfarin treatment 0.986 (0.948), hospital-managed warfarin treatment 0.984 (0.941), major bleed 0.880 (0.841), mild stroke 0.675 (0.641) and severe stroke 0 (0.189). There was wide variation in values between patients and the distributions were highly skewed.

CONCLUSIONS

The results are of value in applying decision analysis to groups of patients. They should be used with caution in reaching decisions about appropriate treatment for individual patients, but may provide a starting point for necessary further exploration of those patients' individual preferences.

The efficiency of the delivery of neonatal care in the UK

BACKGROUND

A recent paper in Journal of Public Health Medicine (O'Neill et al., 2000; 22(1): 108-115) used regression modelling to determine the average costs of neonatal care services for a sample of 49 units in the United Kingdom in 1990-1991, and concluded that economies of scale were present in the sample as a whole. Although this form of modelling is useful, analysis of the efficiency of production for individual units is also important.

METHODS

Data envelopment analysis (DEA) was used to analyse the data set published by O'Neil et al., to determine technical efficiency of neonatal units, measuring efficiency compared with a benchmark efficient frontier, and estimating economies of scale for each unit. Potential cost savings if units were to operate efficiently are estimated.

RESULTS

There is evidence of substantial levels of technical inefficiency. Economies of scale varied between units, with increasing returns in the 36 inefficient units, and mainly constant returns in the 13 efficient units. This suggests that the presence of technical inefficiency was as important as scale inefficiencies. Total cost savings, if all units were operating efficiently, are estimated at ł10.4 million, equivalent to 10 extra units producing 57,000 additional days of care.

CONCLUSIONS

DEA is a technique of great potential value in analysing the efficiency of health care production. As well as inefficiencies in the production of neonatal care in the United Kingdom due to differences in the scale of production, there appears to have been considerable technical inefficiency, which was not due to differences in case mix. The potential cost savings from efficiency gains are large.

Docetaxel-carboplatin as first line chemotherapy for epithelial ovarian cancer

A prospective, non-randomized, multicentre, open, dose-finding study of a carboplatin-docetaxel (C-D) combination as first-line chemotherapy in FIGO stage Ic-IV epithelial ovarian cancer. C-D was given 3-weekly for 6 planned cycles, with a 3-day prophylactic dexamethasone regimen (8 mg b.i.d.). 139 eligible patients (Pts) (median age 56 years, range 28-85) were given a total of 750 cycles of chemotherapy in 5 cohorts: Co1, 32 pts, 169 cycles (C at AUC 5 + D 60 mg/m(2)); Co2, 22 pts, 122 cycles (5 + 75), Co3, 29 pts, 156 cycles (6 + 75), Co4, 27 pts, 146 cycles (7 + 75), Co5, 30 pts, 157 cycles (6 + 85). 110 patients (79%) completed 6 cycles; 17 (12%) stopped due to toxicity. 104 patients (75%) had CTC grade IV neutropenia, and 5 patients (4%) had this associated with fever. There were 2 probable treatment-related deaths. Only 8 patients (6%) experienced grade II-III neurotoxicity (all sensory; no motor > grade I). The maximum tolerated dose was reached in cohorts 4 and 5, and the dose limiting toxicities were myelosuppression and diarrhoea. The overall response rate for the study was 66% (49/74); CA125 response was 75% (70/93). Median progression-free survival was 16.6 months (95% CI 13.3-19.1). Recommended doses are carboplatin AUC 5 (via(51)Cr EDTA) or AUC 6 (if calculated) plus docetaxel 75 mg/m(2). A randomized trial comparing this regimen with carboplatin-paclitaxel has just completed recruitment.

Decision analysis and guidelines for anticoagulant therapy to prevent stroke in patients with atrial fibrillation

BACKGROUND

Clinical guidelines are needed on whether or not to use anticoagulant therapy to prevent stroke in patients with non-valvular atrial fibrillation. We did a Markov decision analysis to model decision-making with regard to warfarin treatment in patients with atrial fibrillation, and used the model to develop evaluative guidelines.

METHODS

The decision analysis involved a systematic literature review supplemented by patients' estimates of the quality of life associated with different states of health, secondary analysis of stroke-registry data, and estimation of service costs; it also incorporated a sensitivity analysis. The derived guidelines were subsequently applied to a cohort of patients with atrial fibrillation.

FINDINGS

We constructed decision tables for 12 age and sex groups. For most risk combinations, warfarin treatment would have decreased health-care costs and increased quality-of-life years, although the clinical decision was sensitive to patients' preferences and to the estimate of warfarin's effectiveness. 97% of women with atrial fibrillation older than 75 years, and 69% aged 65-74 would have been recommended for treatment; for men, the corresponding figures would have been 75% and 53%. With the upper quartile for the loss of quality of life associated with being on warfarin treatment (1.00), all but two of the 116 patients without contraindications would have been treated, whereas with the lower quartile (0.92), only 27 of 116 would have been treated.

INTERPRETATION

Decision analysis is useful in the incorporation of complex probabilistic data into informed decision-making, the identification of factors influencing such decisions, and the subsequent development of evaluative guidelines.

Treatment of multiple sclerosis with interferon beta: an appraisal of cost-effectiveness and quality of life

OBJECTIVE

To evaluate the cost-effectiveness of interferon beta-1b (IFbeta-1b) for relapsing-remitting multiple sclerosis (RRMS).

METHODS

Construction of a cost-effectiveness model using published data on IFbeta-1b effectiveness and the natural history of RRMS, and new data on costs and quality of life (QoL) from a sample of 102 patients with RRMS and resident in northern England.

RESULTS

Poorer QoL was found for patients with multiple sclerosis compared with the general population; those who had had a relapse; those with worse states identified by a clinical measure (expanded disability status scale (EDSS)). Relapses have effects over several months. Health state valuations were higher than in the general population. Costs were higher in relapse than remission and for worse EDSS states. IFbeta-1b costs were larger than cost savings. The best cost-effectiveness estimate was pound28 700 per relapse avoided, which is pound809 900 per QALY gained; or pound328 300 per QALY gained allowing for effects of progression over 5 years. Estimates were robust to changes in assumptions.

CONCLUSIONS

The impact of multiple sclerosis on QoL is substantial. Future trials should base outcomes measurement on QoL and be better linked to natural history and cost data. IFbeta-1b produces important occasional short term QoL gains, but small gains in QALYs overall and large additional costs.

A comparison of the plasma disappearance of iohexol and 99mTc-DTPA for the measurement of glomerular filtration rate (GFR) in diabetes

BACKGROUND

Changes in glomerular filtration rate (GFR) provide a valuable indicator of the progression of diabetic nephropathy. GFR is most commonly measured by the plasma clearance of radioisotopes, however, use of iohexol, a non-ionic radiocontrast medium, is a recently described alternative and has shown good agreement with inulin clearance. A one-compartment model is used for calculating GFR in most Australian centres but a two-compartment model is more accurate.

AIMS

To set up a non-radioisotopic method for assessment of GFR using iohexol, and to compare this with the currently used 99mTc-diethylene-triamine-penta-acetic acid (DTPA) method. Secondly, to compare GFR results using an unmodified one-compartment model with a one-compartment model subjected to the Brochner-Mortensen modification.

METHODS

Twenty-one patients with diabetes had assessment of GFR with simultaneous measurements of 99mTc-DTPA and iohexol plasma clearance. Plasma clearance was determined by the slope intercept method and then modified according to the Brochner-Mortensen equation. Plasma iohexol concentrations were determined by capillary electrophoresis.

RESULTS

There was no significant difference between iohexol and 99mTc-DTPA derived GFR values, difference 4.3+/-7.7 mL/minute (mean+/-SD). This was despite 99mTc-DTPA protein binding demonstrated in the range of 5-10%. Comparison of GFR results using an unmodified one-compartment model with a Brochner-Mortensen corrected one-compartment model showed higher GFR values with the former, in the range of 20-30% for GFR values > 100 mL/minute.

CONCLUSION

Iohexol provides an efficient alternative to radioisotopic methods for serial measurement of GFR in diabetic patients with hyperfiltration, incipient and overt nephropathy. A one-compartment model with its inherent overestimation of GFR should be replaced by the Brochner-Mortensen modified one-compartment model.

Non- and semi-parametric estimation of age and time heterogeneity in repeated cross-sections: an application to self-reported morbidity and general practitioner utilization

Patterns of self-reported morbidity and general practitioner (GP) utilization exhibit complex age, sex and time heterogeneity. Underlying patterns are often obscured by data which are overly 'rough' because of noise associated with adjacent year fluctuations. In this paper we describe methods to obtain smoothed estimates of age, time and birth-cohort effects using data from the General Household Survey (GHS), covering the period 1984-1995/6 inclusive. The methods outlined offer powerful analytic tools to research complex profiles or trends, particularly over age or time. The relationships of the morbidity and GP utilization measures with age, sex and survey year characteristics are estimated non-parametrically using roughness penalized least squares (RPLS). A semi-parametric extension of this model is used to estimate the effect of the morbidity variables on GP utilization. Tests are employed for various forms of age and time heterogeneity including birth-cohort effects. Linear age specifications are rejected for all variables and evidence is found of time heterogeneity in one of the morbidity measures--limiting long-standing illness (LS)--and GP utilization. The advantages of employing non- and semi-parametric estimations in the presence of complex relationships such as those observed for age and time profiles are discussed. Adoption of these techniques by applied econometricians working in health economics is encouraged.

Models of commissioning health services in the British National Health Service: a literature review

The commissioning of health services is an under-researched area and yet it is critical to the way services meet health needs and to the quality of care. Recent emphasis in the United Kingdom and elsewhere has been on a 'primary care led National Health Service', particularly on locality commissioning through primary care groups. However, there are other models of commissioning using 'programmes of care' (focused on diseases or patient groups rather than geography) which may offer greater benefits. There is little research comparing the benefits and costs of these models, and most are not even clearly enough described to be replicated. There will always be a political dimension to models of commissioning, dependent, for example, on the balance of power in the decision-making process. None the less, a broader knowledge of possible models and a willingness to evaluate rigorously are needed if commissioning of health services is to result in better patient care.

Measuring outpatient resource use and case mix in ophthalmology in north east England

OBJECTIVES

To test the extent to which two existing ambulatory case mix measures (Ambulatory Visit Groups and Ambulatory Patient Groups) and other variables can explain resource use variations in ophthalmic outpatient visits.

DESIGN

Three week prospective study of three consultant outpatient clinics.

SETTING

One ophthalmic hospital (Sunderland Eye Infirmary, Sunderland, Tyne and Wear) and three outreach clinics (South Tyneside District Hospital, South Shields, Tyne and Wear; Dryburn Hospital, Durham, Co Durham; and Hartlepool General Hospital, Hartlepool, Cleveland).

SUBJECTS

325 patients who visited ophthalmic outpatient clinics.

MAIN OUTCOME MEASURES

Mean consultation time and mean cost distributions by case mix group, analysed by analysis of variance.

RESULTS

Ambulatory case mix measures can explain some of the variation in resource use for outpatient visits, but different measures differ in the extent to which they can do so. Clinicians' behaviour also accounts for a significant amount of such variation. Simpler measures of visit type, without diagnostic or procedure information, do not explain resource use variations.

CONCLUSIONS

Existing measures perform reasonably well, but their data requirements may preclude their introduction in the National Health Service. Caution is required in advocating simpler measures, however. The influence of clinical practice on resource use variations is important; in this study, most differences between clinicians were not attributable to differences in case mix.

Clinical trials of nimodipine as a potential neuroprotector in ovarian cancer patients treated with cisplatin

Our previous randomised trial in patients with advanced ovarian cancer indicated a significant response and survival advantage for those receiving high-dose (100 mg/m2) as compared with low-dose (50 mg/m2) cisplatin in combination with cyclophosphamide (750 mg/m2). However, this was accompanied by more toxicity; peripheral neuropathy was troublesome, with 32% of patients experiencing > or = WHO grade 2 at the cisplatin dose of 100 mg/m2. Nimodipine is a calcium-channel antagonist that has provided protection from cisplatin-induced neurotoxicity in a rat model system. We performed a pilot study in 50 patients that demonstrated the feasibility of co-administration of nimodipine in a chronic oral dosing schedule with cisplatin-based chemotherapy in an open-label non-randomised trial. This led us to initiate a double-blind, placebo-controlled, randomised trial in patients with ovarian cancer, which was prematurely discontinued because of problems with nausea and vomiting, leading to poor patient compliance, that were not predicted by the pilot study. These studies did not demonstrate a neuroprotective effect for nimodipine. The primary efficacy variable, i.e, the neurotoxicity score at the end of treatment, gave a significantly lower mean for placebo patients than for nimodipine patients. This report details our experience and discusses the reasons for premature termination of the randomised trial.

Less fog on the Tyne? Programme budgeting in Newcastle and North Tyneside

Programme Budgeting (PB) has been widely promoted as a model for the better conduct of the work of Health Authorities in the National Health Service in the United Kingdom. This paper reports on a project which looked at the development of PB in Newcastle and North Tyneside Health Authority (NNTHA), concentrating on the construction of a computerised tool for the compilation and analysis of programme budgets. The main activities carried out were a survey of user requirements for PB, a survey of data availability, the collection of data to construct programme budgets, and development of a relational database for storing and manipulating PB information. The main source of data was the Contract Minimum Data Set, which was supplemented by data from a number of other sources to give comprehensive information on spending in NNTHA. Costed activity data were produced, which could be aggregated in a large number of ways, such as by care setting (inpatient, outpatient, community, general practice, etc.), disease group (ICD9 chapter headings), case mix (Healthcare Resource Groups) and socio-demographic variables (age/sex, locality of GPs practice).

DNA fingerprinting of benign and malignant breast lesions

Paired blood and breast tissue samples from 96 patients undergoing surgical excision of a breast lesion were subjected to DNA fingerprint analysis using the minisatellite probes 33.6 and 33.15. The 'fingerprints' of the blood and breast DNA were compared. DNA fingerprint changes seen were classified as band additions, band deletions or changes in band intensity. Significantly more DNA fingerprint changes were seen in malignant than in benign lesions (probe 33.6, P<0.01; probe 33.15, P=0.01; both probes, P = 0.04). The frequency of the changes detected in the breast cancers was unrelated to tumour grade or the presence of invasion. DNA ploidy was measured in 70 of the breast carcinomas. DNA fingerprint changes were seen in 41 of these, but flow cytometry detected aneuploidy in only 29 tumours (P=0.04). The DNA fingerprinting technique is unlikely to be useful in differentiating between benign and malignant breast lesions as changes were detected in one of the fibroadenomas studied. However, it may be a useful technique in screening tumour DNA for abnormalities suitable for more detailed analysis.

Mature results of a randomized trial of two doses of cisplatin for the treatment of ovarian cancer. Scottish Gynecology Cancer Trials Group

PURPOSE

In 1992, we reported the first results of a randomized study in ovarian cancer, comprising two doses of cisplatin and indicated a significant difference (P = .0008) in median survival. Four years later, we now describe the results of this trial.

PATIENTS AND METHODS

After a median follow-up of 4 years and 9 months, 115 of 159 cases of advanced ovarian cancer, originally randomized to receive six cycles of cyclophosphamide 750 mg/m2 and either a high dose (HD) of 100 mg/m2 cisplatin or a low dose (LD) of 50 mg/m2 (LD) cisplatin, have now died.

RESULTS

The overall survival for HD and LD patients is 32.4% and 26.6%, respectively, and the overall relative death rate is 0.68 (P = .043). This represents a reduction in overall benefit with longer follow-up compared with the first 2 years (relative death rate of 0.52). Toxicity, particularly neurotoxicity, is still evident in the fourth year (10/31 on HD compared with 1/24 on LD).

CONCLUSION

Our recommended dose of cisplatin in combination schedule is therefore 75 mg/m2, representing the optimal balance between efficacy and toxicity.

Investigating hospital efficiency in the new NHS: the role of the translog cost function

The reforms to the United Kingdom's National Health Service (NHS) of recent years have greatly increased the role of economic incentives in the hospital sector. Hospitals now have to compete for the business of GP and health authority purchasers and are assumed to have an incentive to minimise costs. This makes the analysis of cost functions much more relevant than has previously been the case. The objective of this paper is to assess the potential usefulness of the translog cost function applied in the NHS internal market. Three main issues are identified that limit the role of this type of cost function in the internal market: the adequacy of the econometric model (including data quality); the assumptions underlying the model, and; the interpretation of economies of scale, marginal costs and economies of scope that can be derived from such a cost function. It is concluded that at present the application of translog cost function analysis in the NHS is of limited usefulness, but that it does indicate areas for further methodological research.

The efficiency of Scottish acute hospitals: an application of data envelopment analysis

Measurement of the efficiency of health services would aid the promotion of a better allocation of health care resources. Economic analysis suggests a number of ways of defining and measuring efficiency. However, this rarely informs measures used in health service management. This paper looks at the potential for the use in the United Kingdom's National Health Service of the linear programming based method of data envelopment analysis (DEA). DEA is applied to data from 75 UK acute hospitals. The results demonstrate the capacity of DEA to produce a user-friendly array of results, based on sound theoretical underpinnings. These range from the measurement of relative efficiencies to quantified suggestions as to how hospitals may improve efficiency, by examining both their own efficiency and that of comparable units. Information is provided both about individual hospitals and the sample as a whole. DEA is also able to distinguish between hospitals demonstrating differing returns to scale. Our findings suggest that, although still very much under development, DEA is usable and, given the weakness of current means of measuring efficiency in the National Health Service, that DEA has a strong claim for further consideration.

Clearing the fog on the Tyne: programme budgeting in Newcastle and North Tyneside Health Authority

When the internal market was introduced, the National Health Service Management Executive envisaged purchasing as a process by which contracts would be developed from information concerning current services, modified in the light of strategic purchasing objectives, epidemiological needs assessment and indicators of comparative performance and efficiency. Our concern in this paper is with the promotion of efficiency. We distinguish between three levels and, in particular, discuss how the programme budgeting and marginal analysis framework can be used in the promotion of efficiency at 'top-level' decision making. PB/MA can be used to give a focus to needs assessment and forge explicit links between individual contracts within a well defined health strategy. The objectives of the current research and development ongoing within Newcastle and North Tyneside Health Authority are outlined. The intention is to achieve programme budgeting which is more responsive to decision makers' needs and is consistent with the contracting cycle. However, a number of constraints are expected to impede development. They include transferability of national and international information; absence of local information on epidemiology, effectiveness and cost-effectiveness; limitations on the accuracy and precision of programme budgets; and whether purchasers make strategic decisions based on macro budgets. The contribution of each of these constraints is explored.

An evaluation of ambulatory visit groups in rheumatology out-patients

The development of case mix measures for National Health Service (NHS) care has become of great importance recently. Much effort has been put into devising measures for in-patient care, but measures for ambulatory (outpatient, day care and primary care) visits are less developed. Ambulatory Visit Groups (AVGs) is an American system devised to aggregate ambulatory visits into iso-resource groups. However, some assumptions made in the construction of the AVG system may not hold for the UK health service, including the use of consultation time as a proxy for the total resource use associated with the out-patient attendance. To test AVGs in the UK context, a three-month prospective study of rheumatology out-patient attendances at two hospitals in Newcastle upon Tyne assembled a database of 3393 'visits', together with resource use data. The AVGs derived from these were analysed to evaluate the homogeneity of the groups with respect to consultation resource use, and the degree to which consultation time can be considered a proxy for resource use in this setting. Consultation time distributions were markedly skewed, and required log transformation before analysis. Variation in log consultation time was found to depend as much on the clinician as on the AVG, and the two were observed to interact. Resource use distributions were also skewed, and were similarly transformed for analysis. Non-parametric analysis of variance showed resource use to be significantly associated with AVG, but the amount of variation associated with the AVG appeared to be small and inconsistent.(ABSTRACT TRUNCATED AT 250 WORDS)

Incomplete excision of CIN in conization: further excision or conservative management?

The aim of this study was to investigate the experience of the further management in 112 cases with histological diagnosis of incomplete excision of CIN in cone biopsy. Two groups of women were studied. The women in the first group (n = 78) had a second excision while the women in the second group (n = 34) underwent conservative management with cytology and colposcopy. The histologic, cytologic and colposcopic findings in the women of both groups were compared. From the first group 38% had a second cone, 62% an hysterectomy; in 5 cases the second cone was followed by hysterectomy and the histology was negative in 75% and 65%, respectively. No indication of residual disease was found within 2-10 years of follow-up in any of the women in the second group. According to our study and being aware of the natural history of CIN, we can conclude that the decision for further excision should not be based exclusively on the histology report of involved margins, but should only be taken after careful cytological and colposcopic selection of the cases.

Lanterns in the jungle: is the NHS driven by the wrong kind of efficiency?

The performance of the National Health Service is assessed in part by an Efficiency Index (EI) which is applied to the service as a whole as well as to individual health authorities. The EI relates increases in the amount of patient care activity to increases in total expenditure. The index can give a misleading impression of performance, creates perverse incentives and is at odds with the overall strategy of the health service which is to place greater emphasis on the promotion of health and to provide more care in primary and community-based settings. The philosophy, validity and appropriateness of the EI are discussed.