The impact of patient choice and waiting time on the demand for health care: results from the London Patient Choice project

In a number of countries where health care is publicly funded, policies to introduce greater patient choice are being implemented. In most cases patient choice is seen as an instrument to reduce waiting times for elective (non-emergency) hospital services. An important issue is whether facilitating greater patient choice will increase the demand for health care and thereby undermine the achievement of reduced waiting times. A large scale pilot of choice in the London metropolitan area permits a test of the hypothesis that choice will affect demand. This paper estimates a model of the demand for elective surgery using a panel of 150 English acute hospitals over the period 1995 to 2004 for three surgical specialties. It examines whether demand shifted following the introduction of the London Patient Choice Project in 2002. The results suggest that the choice project only shifted NHS inpatient demand in orthopaedics and that this shift was inwards.     

Mucodyne: the economics of preventing surgery for grommets

Summary

Prudent management for glue ear currently entails a month period of watchful waiting before grommet insertion if the problem has not been resolved. The costs of administering Mucodyne during the watchful waiting period and the potential resources released from a reduction in the number of grommet insertions were assessed from the perspective of the National Health Service (NHS) in the UK. A decision analysis model was used to estimate the probability of resolution of glue ear with both approaches, and the costs of them combined with the resource implications of surgery and its outcomes. The cost difference between the two approaches amounts to £11.06 per patient, based on a difference of 9% between the Mucodyne group and watchful waiting - this represents a number needed to treat (NNT) of 11. The 'break-even' NNT to prevent grommet surgery is 15.2 - an absolute difference of 6.5% of children benefiting from the Mucodyne treatment.     

Can a Mixed Health Care System be Desirable on Equity Grounds?*

Should health care provision be public, private, or both? We consider this question in a setting where people differ in their earnings capacity and face some illness risk. We assume that illness reduces an individual's time endowment when waiting for treatment. Treatment can be obtained in a competitive private sector (through private insurance) or in the National Health Service (NHS) where it is provided free of charge but after some (endogenous) waiting time. The equilibrium in the health care sector consists of a waiting time in the NHS such that no patient wants to switch health care provider. This equilibrium is governed by two public policies: the income tax system and the size of the NHS. We find that: (i) a mixed system with a small NHS is never desirable; (ii) actuarially fair sickness insurance is never desirable either; (iii) a mixed system with a sufficiently large NHS may improve on a pure public system if the dispersion of earnings capacities is large enough; and (iv) the welfare gains from such a mixed system are not likely to be significant.     

Nabumetone compared with Ibuprofen and a weighted NSAID combination: an economic evaluation

Summary

An economic evaluation has been performed to assess the cost effectiveness of using nabumetone to treat Osteoarthritis (OA) or Rheumatoid Arthritis (RA) compared to alternative NSAIDs (plain NSAIDs only, ie. excludes combinations). Clinical decision analysis has been used to model the costs and outcomes of treatment building on the results of a large, open label, randomised, controlled, multicentre US clinical study, from an NHS perspective. In the treatment of OA/RA, nabumetone carries a lower risk of major side effects and potential associated mortality, than either ibuprofen or a weighted NSAID comparator. The cost per life year gained, by prescribing nabumetone, in place of other NSAIDs, ranges from £1,656 to £3,087.

If reducing the risk of major side effects is a priority then the additional potential costs of prescribing Nabumetone to achieve this end compares favourably to many expenditures already made within the NHS. On this basis, prescribing nabumetone for OA/RA may be considered a cost effective use of resources from a health service perspective.     

Incentives and targets in hospital care: Evidence from a natural experiment

Performance targets are commonly used in the public sector, despite their well known problems when organisations have multiple objectives and performance is difficult to measure. It is possible that such targets may work where there is considerable consensus that performance needs to be improved. We investigate this possibility by examining the response of the English National Health Service to high profile waiting time targets. We exploit a natural policy experiment between two countries of the UK (England and Scotland) to establish the global effectiveness of the targets. We then use a within-England hospital analysis to confirm that responses vary by treatment intensity and to control for differences in resources which may accompany targets. We find that targets met their goals of reducing waiting times without diverting activity from other less well monitored aspects of health care and without decreasing patient health on exit from hospital.     

Competition and waiting times in hospital markets

This paper studies the impact of hospital competition on waiting times. We use a Salop-type model, with hospitals that differ in (geographical) location and, potentially, waiting time, and two types of patients: high-benefit patients who choose between neighbouring hospitals (competitive segment), and low-benefit patients who decide whether or not to demand treatment from the closest hospital (monopoly segment). Compared with a benchmark case of monopoly, we find that hospital competition leads to longer waiting times in equilibrium if the competitive segment is sufficiently large. Given a policy regime of hospital competition, the effect of increased competition depends on the parameter of measurement: Lower travelling costs increase waiting times, higher hospital density reduces waiting times, while the effect of a larger competitive segment is ambiguous. We also show that, if the competitive segment is large, hospital competition is socially preferable to monopoly only if the (regulated) treatment price is sufficiently high.     

Potential unrecognised costs of clopidogrel pretreatment in acute coronary syndrome

Abstract

Objective: To examine adherence in clinical practice to the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations of observing a 5-day waiting period after clopidogrel administration before undergoing coronary artery bypass graft (CABG) surgery and to examine the costs of waiting.

Methods: This retrospective study used a nationwide inpatient database (Solucient ACTracker) to identify patients who were admitted for acute coronary syndrome (ACS), and who had same-stay CABG. Cost of additional days of stay was estimated using regression analysis.

Results: The recommended 5-day waiting was adhered to in 16.9% (n=3,809) of patients. The percentage of patients with ACS undergoing CABG surgery on day 0 was 14.6%. Adherence to the waiting was higher for teaching and rural hospitals; and in female and elderly patients and urgent admissions.

Conclusions: The recommended 5-day waiting for CABG surgery after clopidogrel treatment is poorly adhered to in clinical practice. This study was unable to determine specific reasons for the low adherence; however, there may be a compromise between the clinically urgent need for revascularisation and increased risk of bleeding, as well as economic costs associated with waiting. The cost of an additional hospital day in this group of patients was approximately £1,400 per day or £7,000 for 5 days. Thus, a full 5-day wait would have a significant economic impact on hospital costs.     

The influence of black markets on a queue-rationed centrally planned economy

In centrally planned economies in which prices are fixed, and the rationing mechanism is waiting line queues, we show that an equilibrium of waiting times exists. We then introduce a “black market” in which individuals can trade commodities that they have acquired through the official economy. An equilibrium of black market prices and waiting times is shown to exist; further, the economy with a black market is “queue-efficient.”. However, the introduction of black markets is not necessarily a Pareto improvement over an economy without black markets (even when we allow winners to compensate losers).     

Waiting times and equilibrium selection

Summary. This paper shows how graphs can be used to calculate waiting times in models of equilibrium selection. It also shows how reducing the state space can simplify the calculations of both waiting times and selected equilibria. The results are applied to potential games and games with strategic complementarities.Received: 31 December 2002, Revised: 25 October 2003, JEL Classification Numbers: C72, C73.Alan Beggs: I am grateful to an anonymous referee for helpful comments.     

Cost-consequence analysis of different active flowable hemostatic matrices in cardiac surgical procedures

Background: A recent retrospective comparative effectiveness study found that use of the FLOSEAL Hemostatic Matrix in cardiac surgery was associated with significantly lower risks of complications, blood transfusions, surgical revisions, and shorter length of surgery than use of SURGIFLO Hemostatic Matrix. These outcome improvements in cardiac surgery procedures may translate to economic savings for hospitals and payers.

Objective: The objective of this study was to estimate the cost-consequence of two flowable hemostatic matrices (FLOSEAL or SURGIFLO) in cardiac surgeries for US hospitals.

Methods: A cost-consequence model was constructed using clinical outcomes from a previously published retrospective comparative effectiveness study of FLOSEAL vs SURGIFLO in adult cardiac surgeries. The model accounted for the reported differences between these products in length of surgery, rates of major and minor complications, surgical revisions, and blood product transfusions. Costs were derived from Healthcare Cost and Utilization Project’s National Inpatient Sample (NIS) 2012 database and converted to 2015?US dollars. Savings were modeled for a hospital performing 245 cardiac surgeries annually, as identified as the average for hospitals in the NIS dataset. One-way sensitivity analysis and probabilistic sensitivity analysis were performed to test model robustness.

Results: The results suggest that if FLOSEAL is utilized in a hospital that performs 245 mixed cardiac surgery procedures annually, 11 major complications, 31 minor complications, nine surgical revisions, 79 blood product transfusions, and 260.3?h of cumulative operating time could be avoided. These improved outcomes correspond to a net annualized saving of $1,532,896. Cost savings remained consistent between $1.3m and $1.8m and between $911k and $2.4m, even after accounting for the uncertainty around clinical and cost inputs, in a one-way and probabilistic sensitivity analysis, respectively.

Conclusions: Outcome differences associated with FLOSEAL vs SURGIFLO that were previously reported in a comparative effectiveness study may result in substantial cost savings for US hospitals.     

Mental Health and Wellbeing and Unemployment

This article examines the relationship between mental health and wellbeing and unemployment utilising the 1995 National Health Survey (1995 NHS) and the 1997 National Survey of Mental Health and Wellbeing of Adults (1997 SMHWB) data sets. Three indicators of mental health and wellbeing are adopted. The first is a psychological wellbeing measure derived from responses to questions included in the 1995 NHS on time felt down, happy, peaceful, and nervous (the SF-36 mental health scale). The second indicator relates to diagnoses of mental disorders including substance use disorders, affective disorders and anxiety disorders. Our final indicator relates to suicidal thoughts and plans and (unsuccessful) suicide attempts. On the basis of these measures, unemployed persons exhibit poorer mental health and wellbeing outcomes than the full-time employed.     

Incorporating adherence in cost-effectiveness analyses of asthma: a systematic review

Abstract

Aims: Non-adherence is associated with poor clinical outcomes among patients with asthma. While cost-effectiveness analysis (CEA) is increasingly used to inform value assessment of the interventions, most do not take into account adherence in the analyses. This study aims to: (1) Understand the extent of studies considering adherence as part of the economic analyses, and (2) summarize the methods of incorporating adherence in the economic models.

Materials and methods: A literature search was performed from the inception to February 2018 using four databases: PubMed, EMBASE, NHS EED, and the Tufts CEA registry. Decision model-based CEA of asthma were identified. Outcomes of interest were the number of studies incorporating adherence in the economic models, and the incorporating methods. All data were extracted using a standardized data collection form.

Results: From 1,587 articles, 23 studies were decision model-based CEA of asthma, of which four CEA (17.4%) incorporated adherence in the analyses. Only the method of incorporating adherence by adjusting treatment effectiveness according to adherence levels was demonstrated in this review. Two approaches were used to derive the associations between adherence and effectiveness. The first approach was to apply a mathematical formula, developed by an expert panel, and the second was to extrapolate the associations from previous published studies. The adherence-adjusted effectiveness was then incorporated in the economic models.

Conclusions: A very low number of CEA of asthma incorporated adherence in the analyses. All the CEA adjusted treatment effectiveness according to adherence levels, applied to the economic models.     

MEASURING AND IMPROVING TECHNICAL EFFICIENCY IN UK POST OFFICE COUNTERS USING DATA ENVELOPMENT ANALYSIS

This paper sought to establish how technically efficient Post Office Counters is nationally and regionally. The method by which this was determined is data envelopment analysis, applied to data for 1989 on 1281 Crown post offices. The input used was labour, and outputs consisted of average waiting times as a measure of quality of service, and nine different categories of counter transactions. Nationally it was found that technical efficiency could be significantly improved by making more efficient use of labour inputs and reducing average waiting times. Wide disparities were found in regional efficiency and it was hypothesized that these relative differences were due to differing working practices, turnovers of staff and local labour market conditions. It was also concluded for the period studied that some structural inefficiency existed due to the existence of inefficient working practices and the lack of computerization of transaction procedures.     

Hospital economic impact from hemostatic matrix usage in cardiac surgery

Objective:

Improved health outcomes can result in economic savings for hospitals and payers. While effectiveness of topical hemostatic agents in cardiac surgery has been demonstrated, evaluations of their economic benefit are limited. This study quantifies the cost consequences to hospitals, based on clinical outcomes, from using a flowable hemostatic matrix vs non-flowable topical hemostatic agents in cardiac surgery.

Research design and methods:

Applying clinical outcomes from a prospective randomized clinical trial, a cost consequence framework was utilized to model the economic impact of comparator groups. From that study, clinical outcomes were obtained and analyzed for a flowable hemostatic matrix (FLOSEAL, Baxter Healthcare Corporation) vs non-flowable topical hemostats (SURGICEL Nu-Knit, Ethicon–Johnson &; Johnson; GELFOAM, Pfizer). Costing analyses focused on the following outcomes: complications, blood transfusions, surgical revisions, and operating room (OR) time. Cardiac surgery costs were analyzed and expressed in 2012 US dollars based on available literature searches and US data. Comparator group variability in cost consequences (i.e., cost savings) was calculated based on annualized impact and scenario testing.

Results:

Results suggest that if a flowable hemostatic matrix (rather than a non-flowable hemostat) was utilized exclusively in 600 mixed cardiac surgeries annually, a hospital could improve patient outcomes by a reduction of 33 major complications, 76 minor complications, 54 surgical revisions, 194 transfusions, and 242?h of OR time. These outcomes correspond to a net annualized cost consequence savings of $5.38 million, with complication avoidance as the largest contributor.

Conclusions:

This cost consequence framework and supportive modeling was used to evaluate the hospital economic impact of outcomes resulting from the usage of various hemostatic agents. These analyses support that cost savings can be achieved from routine use of a flowable hemostatic matrix, rather than a non-flowable topical hemostat, in cardiac surgery.     

Multi-product costs and standby capacity derived from queuing theory: the case of Belgian hospitals

Empirical hospital cost function studies can be divided into two categories: studies estimating traditional multi-product cost functions and studies including demand uncertainty (assuming that hospitals provide standby capacity to cope with uncertain demand and stressing that the relationship between the uncertain demand, excess capacity and costs should be investigated). Most studies include (the inverse of) the occupancy rate in a relatively basic cost function. The first contribution of this paper is to incorporate an indicator of reserve capacity into a genuine multi-product cost function. The second contribution is to propose an alternative indicator to proxy the reserve margin. The often used occupancy rate has an important shortcoming: the same occupancy rate can hide different turnaway probabilities and waiting times, obscuring the true degree of reservation quality. Since turnaway probabilities and waiting times are typical queuing theory indicators, an indicator for average waiting time (derived from queuing theory) is incorporated into a proper multi-product cost function to capture the degree of standby capacity into a proper multi-product cost function. The study uses 1997 data on Belgian general care hospitals to estimate a multi-product cost function and calculate cost elasticities, marginal costs and the degree of economies of scale. The results further show that providing standby capacity has a significant impact on total costs.     

The source of some paradoxes from social choice and probability

An elementary argument is developed to explain and unite several paradoxes coming from probability and from social choice. This geometric approach is illustrated with new results about the intransitivities of election rankings over subsets of alternatives, agenda manipulation, conditional probability, and waiting times.     

IS THERE A ‘SECESSION OF THE WEALTHY’? PRIVATE HEALTH INSURANCE UPTAKE AND NATIONAL HEALTH SYSTEM SUPPORT

The purchase of private health insurance (PHI) as a means to partially supplement the National Health System (NHS) coverage is often regarded as a potential signal for a declining support for the NHS. Exploiting the fact that PHI is typically purchased by the most affluent, in this paper we test the so called ‘secession of the wealthy’ hypothesis whereby the likelihood of expressing ‘lack of support for the NHS’ increases with having supplementary PHI. Using empirical data from Catalonia, we draw upon an empirical strategy that circumvents an obvious simultaneity problem by estimating both a recursive bivariate probit as well as an IV probit. After controlling for insurance premium, household income and other socio‐demographic determinants, we find that the purchase of PHI reduces the propensity of individuals to support the NHS. We also find evidence that PHI is a luxury good and sensitive to fiscal incentives.     

Assessment of Resource Use and Costs Associated with Parathyroidectomy for Secondary Hyperparathyroidism in End Stage Renal Disease in the UK

Introduction:

Secondary hyperparathyroidism (SHPT) is a major complication of end stage renal disease (ESRD). For the National Health Service (NHS) to make appropriate choices between medical and surgical management, it needs to understand the cost implications of each. A recent pilot study suggested that the current NHS healthcare resource group tariff for parathyroidectomy (PTX) (£2071 and £1859 in patients with and without complications, respectively) is not representative of the true costs of surgery in patients with SHPT.

Objective:

This study aims to provide an estimate of healthcare resources used to manage patients and estimate the cost of PTX in a UK tertiary care centre.

Methods:

Resource use was identified by combining data from the Proton renal database and routine hospital data for adults undergoing PTX for SHPT at the University Hospital of Wales, Cardiff, from 2000–2008. Data were supplemented by a questionnaire, completed by clinicians in six centres across the UK. Costs were obtained from NHS reference costs, British National Formulary and published literature. Costs were applied for the pre-surgical, surgical, peri-surgical, and post-surgical periods so as to calculate the total cost associated with PTX.

Results:

One hundred and twenty-four patients (mean age?=?51.0 years) were identified in the database and 79 from the questionnaires. The main costs identified in the database were the surgical stay (mean?=?£4066, SD?=?£,130), the first month post-discharge (£465, SD?=?£176), and 3 months prior to surgery (£399, SD?=?£188); the average total cost was £4932 (SD?=?£4129). From the questionnaires the total cost was £5459 (SD?=?£943). It is possible that the study was limited due to missing data within the database, as well as the possibility of recall bias associated with the clinicians completing the questionnaires.

Conclusion:

This analysis suggests that the costs associated with PTX in SHPT exceed the current NHS tariffs for PTX. The cost implications associated with PTX need to be considered in the context of clinical assessment and decision-making, but healthcare policy and planning may warrant review in the light of these results.     

Modelling the economic impact of recombinant activated Factor VII compared to activated prothrombin-complex concentrate in the home treatment of a mild to moderate bleed in adults with inhibitors to clotting Factors VIII and IX in the UK

Summary

This study estimated the costs and consequences of using recombinant activated Factor VII (rFVIIa; NovoSeven®) at home, compared to activated prothrombin-complex concentrate (aPCC; FEIBA®*) at home, to manage a minor (i.e. mild to moderate) bleeding episode in adults with high titre, high responding inhibitors (>10 BU). The analysis was performed from the perspective of the UK's National Health Service (NHS).

NovoSeven and FEIBA are registered trademarks of Novo Nordisk and Baxter Healthcare, respectively.

Clinical outcomes and resource utilisation attributable to managing a minor bleed were obtained from published literature, supplemented with information about treatment patterns and associated resource utilisation derived from interviews with a panel of 22 consultant haematologists experienced in managing inhibitor patients. Using these data sources a decision tree modelling the management of a minor bleed, initially at home, was constructed. Unit resource costs at 1999/2000 prices were applied to the resource utilisation estimates in the model to estimate the expected NHS cost of managing a minor bleeding episode. Consensus on the probabilities and resource utilisation estimates in the model were reached at a meeting comprising seven panel members.

The expected NHS cost of managing a minor bleeding episode initially treated with rFVIIa or aPCC at home was estimated to be £12,944 and £14,645, respectively. Additionally, the expected time to resolving a minor bleeding episode when initially treated with rFVIIa or aPCC at home was estimated to be 32 hours and 60 hours, respectively. Hence, rFVIIa improves clinical outcome compared to aPCC, but at no additional cost to the NHS, resulting in rFVIIa being the cost-effective treatment. This finding warrants further investigation in a prospective, comparative, randomised, controlled study.