ORCID Profile
0000-0003-4689-265X
Current Organisation
University of York
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Publisher: National Institute for Health and Care Research
Date: 09-2019
DOI: 10.3310/HSDR07320
Abstract: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. The objectives were to assess whether or not the QI programme improves 90-day survival after emergency abdominal surgery to assess effects on 180-day survival, hospital stay and hospital readmission and to better understand these findings through an integrated process evaluation, ethnographic study and cost-effectiveness analysis. This was a stepped-wedge cluster randomised trial. Hospitals were organised into 15 geographical clusters, and commenced the QI programme in random order over 85 weeks. Analyses were performed on an intention-to-treat basis. The primary outcome was analysed using a mixed-effects parametric survival model, adjusting for time-related effects. Ethnographic and economics data were collected in six hospitals. The process evaluation included all hospitals. The trial was set in acute surgical services of 93 NHS hospitals. Patients aged ≥ 40 years who were undergoing emergency abdominal surgery were eligible. The intervention was a QI programme to implement an evidence-based care pathway. The primary outcome measure was mortality within 90 days of surgery. Secondary outcomes were mortality within 180 days, length of hospital stay and hospital readmission within 180 days. The main economic measure was the quality-adjusted life-years. Data were obtained from the National Emergency Laparotomy Audit database qualitative interviews and ethnographic observations quality-of-life and NHS resource use data were collected via questionnaires. Of 15,873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 participants in the usual care group and 7374 in the QI group. The primary outcome occurred in 1393 participants in the usual care group (16%), compared with 1210 patients in the QI group (16%) [QI vs. usual care hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.96 to 1.28]. No differences were found in mortality at 180 days or hospital readmission there was a small increase in hospital stay in the QI group (HR for discharge 0.90, 95% CI 0.83 to 0.97). There were only modest improvements in care processes following QI implementation. The ethnographic study revealed good QI engagement, but limited time and resources to implement change, affecting which processes teams addressed, the rate of change and eventual success. In some sites, there were challenges around prioritising the intervention in busy environments and in obtaining senior engagement. The intervention is unlikely to be cost-effective at standard cost-effectiveness thresholds, but may be cost-effective over the lifetime horizon. Substantial delays were encountered in securing data access to national registries. Fewer patients than expected underwent surgery and the mortality rate was lower than anticipated. There was no survival benefit from a QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. The modest impact of the intervention on process measures, despite good clinician engagement, may have been limited by the time and resources needed to improve patient care. Future QI programmes must balance intervention complexity with the practical realities of NHS services to ensure that such programmes can be delivered with the resources available. Current Controlled Trials ISRCTN80682973 and The Lancet protocol 13PRT/7655. This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research Vol. 7, No. 32. See the NIHR Journals Library website for further project information.
Publisher: Springer Science and Business Media LLC
Date: 09-06-2018
DOI: 10.1007/S40258-018-0400-Z
Abstract: Diabetic foot ulceration (DFU) is a common and serious complication among diabetic patients. A medical device has been developed to prevent the occurrence of DFU. The aim of this study was to investigate the willingness to pay (WTP) for this device among the general public in the UK. A contingent valuation survey was administered to 1051 participants through an online survey including questions on socio-demographic characteristics, self-reported health, knowledge of diabetes and medical devices, and WTP. A two-part model was used to analyse determinants of WTP, including a logistic model in the first part and a generalised linear model with a log-transformed WTP in the second part. More than half (55.9%) of the participants expressed a positive WTP. The annual mean (standard deviation) and median (interquartile range) WTP values were £76.9 (69.1) and £50 (80), respectively. Older age, middle-level education, good/excellent self-reported health, visiting doctors once/2-5 times, diabetes experience, medical device experience and more than average self-perceived likelihood of using similar devices were associated with a higher likelihood of willingness to pay. Younger age, male gender and higher household income were associated with higher WTP values. This study demonstrated that people are willing to pay for this device and they tend to contribute when they have experience of diabetes or similar devices and perceive self-benefit.
Publisher: Wiley
Date: 10-08-2018
DOI: 10.1002/GPS.4771
Abstract: Knowledge is limited about the standardised instruments used to collect resource use and quality of life data alongside trials of dementia interventions. This review aimed to identify the trials using such instruments in order to guide the design of future trial-based cost-effectiveness studies. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement, this review examined all original, peer-reviewed research in major databases and general searches published until June 2017, including randomised clinical trials, pilot studies, or feasibility studies about interventions for older adults with dementia or cognitive impairment. Forty-one studies were identified. Only 8 collected the resource use data using adapted Client Service Receipt Inventory (CSRI), Resource Use Inventory (RUI), cost diary, or study-specific questionnaire. Quality of life was assessed using a wide range of instruments. The most frequently used dementia-specific instrument was Quality of Life in Alzheimer's Disease (QOL-AD) and Dementia Quality of Life questionnaire (DEMQOL). Among the generic measures, EuroQol 5-dimentison (EQ-5D) was mostly used to collect health utility data, and Short Form surveys (SF-36 or SF-12) were widely to measure general health. Several useful resource use and quality of life measurement instruments have been identified by this review. For resource use, CSRI was mostly used, but no studies have used Resource Utilisation in Dementia (RUD) for quality of life, we recommend the inclusion of dementia-specific DEMQOL, generic SF-12, and health utility EQ-5D-5L, based on both self-report and proxy-report.
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
No related grants have been discovered for Fan Yang.