Journal of health services research & policy
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J Health Serv Res Policy · Apr 1999
ReviewThreats to applicability of randomised trials: exclusions and selective participation.
Although the randomised controlled trial (RCT) is regarded as the 'gold standard' in terms of evaluating the effectiveness of interventions, it is susceptible to challenges to its external validity if those participating are unrepresentative of the reference population for whom the intervention in question is intended. In the past, reporting on numbers and types of potential subjects that have been excluded by design, and centres, clinicians or patients that have elected not to participate, has generally been poor, and the threat to inference posed by possible selection bias is unclear. ⋯ Narrow inclusion criteria may offer benefits such as increased precision and reduced loss to follow-up, but there are important disadvantages, such as uncertainty about extrapolation of results, which may result in denial of effective treatment to groups who might benefit, and delay in obtaining definitive results because of reduced recruitment rate. Selective participation by teaching centres and sicker patients in treatment RCTs may exaggerate the measured treatment effect. Prevention trials, on the other hand, may underestimate effects as participants have less capacity to benefit.
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J Health Serv Res Policy · Apr 1999
Historical ArticleGovernment funding of the UK National Health Service: what does the historical record reveal?
To examine the historic funding record of the UK National Health Service (NHS) by year (1948-1997), political administration and political party. ⋯ As a guide to voting, this analysis may confirm some prejudices. However, judging the performance of political administrations in relation to the NHS is rather more complex than a macro analysis of financial inputs alone suggests. The apparently weak relationship between inputs and outputs and the possible ability of governments to increase productivity by restricting inputs (and hence partially to deflect criticism of their funding policy) perhaps confirms other prejudices about the productive slack of large organisations. Again, however, care should be taken in the interpretation of the macro analysis, since the potential costs (e.g. reduced quality) arising from parsimonious funding are not captured by the global output measure used in this analysis.
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J Health Serv Res Policy · Jan 1999
Comparative StudyPoint of care testing in the accident and emergency department: a cost analysis and exploration of financial incentives to use the technology within the hospital.
To compare the costs of current arrangements for testing emergency blood samples from patients attending an accident and emergency (A&E) department in a large teaching hospital in England with point of care testing (POCT). ⋯ Introducing POCT results in lower average costs per test. The supplemental option will result in significantly increased costs to the hospital. The replacement option can lead to significant savings. The internal cross-charging arrangements between departments that exist in this hospital may mean that supplemental implementation of POCT could be potentially 'profitable' for the A&E department, but would result in higher expenditure for the hospital as a whole.
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Reducing the costs of management appears an easy target for those seeking to generate savings or to promote better spending in the National Health Service (NHS). However, an assessment of the appropriate amount of spending on management requires an evaluation of how much management contributes to organizational performance. ⋯ The evidence is not yet strong enough to draw a general conclusion that management costs in NHS acute hospitals are too high or that an undiscriminating reduction in management costs would have no detrimental effects on hospital performance. However, the findings should prompt managers to identify ways in which their activities are productive and how these can be measured, and what distinguishes effective from ineffective management.
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J Health Serv Res Policy · Jul 1998
Review Comparative StudyManaged care: US research evidence and its lessons for the NHS.
To review the high quality US evidence on performance of managed health care organisations and the available US evidence on specific managed care techniques; namely, financial incentives, utilisation management and review, physician profiling and disease management. ⋯ Applying US evidence is complicated by an irrelevant comparator and a higher baseline of utilisation. Managed care brought Americans the familiar NHS practices of population-based health care and resource management through gatekeeping; hence, changes due to UK adoption of managed care techniques may be modest. US evidence should be used to generate hypotheses, not to predict UK behaviour.