TableA.7 Cost effectiveness of GI services: summary of articles examined for access to specialist care

AuthorsResearch setting and year of studyStudy designSample sizeTopic of documentResults and conclusionsComments
Association of Coloproctology of Great Britain and Ireland753UK (2000)Postal surveyReplies from 75 centres covering 26.5 millionThe number of staff needed for coloproctologyExtra staff (full time equivalent) required for the UK were: 170 surgeons; 18 histopathologists; 72 oncologists; 42 radiologists; 60 palliative care nurses; 98 colorectal cancer nurses; 140 stomatherapy nurses; and 760 other colorectal specialist nurses. Some solution to this shortage can be offered by involving more GPs and endoscopy nursesA good mapping of needs; it does deal with the most cost effective ways to reach the target
South Wales Cancer Network754UK (Wales) (2002)ReviewNAService development planBy end of 2004:Reflect local workforce and skill mix required.Examine the training requirements Undertake a mapping exercise to establish current availability and future needs of specialist nursing workforce.By end of 2005:Agree long term service model in response to NICE guidelinesMainly a research agenda document
Guillou et al776UK (1996)ReviewNAMinimal access GI surgeryEvidence on cost effectiveness of laporoscopic v conventional cholesystectomy too thin to reportMost evidence is from the USA, where charges rather than costs are used. Authors (quite rightly) warn about this
MacKenzie et al597UK (1999–2001)RCT552 Intervention group; 565 control GroupMethod of investigating large bowel symptomsNHS and patient borne costs were included. The study had a three month follow-up. Total costs per patient were £307 (consultant led) and £203 (open access), respectively. The difference was not statistically significantSD and ranges of cost figures were not reported. Further research is required to identify the reasons for non-attendance
Bowles et al752UK (England) (2002)Cross sectional study (4 months follow-up)9223 colonoscopies across 68 hospital units (5 teaching hospitals, 18 DGH, 7 private hospitals, and 1 paediatric unit)To study the availability and the quality of adult and paediatric colonoscopy in three NHS regionsThere is a serious underprovision of colonoscopy service in most NHS hospitals. Only 17% of colonoscopists had received supervised training for their first 100 coloscopies and only 39.3% had attended a training courseThe study did not include an economic component
Burling et al755UK (2003)Observational study138 DepartmentsThe provision of CT colonography in UK radiology departmentsCT colonography is widely available in the UK, with about one third of respondents offering a service. Experience and throughput varies considerably. Limited CT scanner facility is the major barrier to further disseminationThe paper does not include an economic dimension. Although there is little evidence on the cost effectiveness of the technique, this is widely available
Sawczenko et al756UK (1998–99)Prospective population based survey739 new IBD cases across 3247 paediatricians, adult gastroenterologists, and surgeons in the UKVariation in the management of children with newly diagnosed IBDThis study suggests that in many, if not the majority, of institutions there is no designated care pathway for the management of childhood IBD. Current specialist provision, and initial investigation and treatment of IBD, are heterogeneousThere is no economic analysis
Kennedy et al683UK (2003)RCT700 Patients (297 intervention, 403, control) across 19 hospitals in northwest EnglandExplore models for training health professionals in methods to promote and support self care, study long term effect, and assess whether faster treatment reduces the duration of relapses in IBDAfter one year, the intervention resulted in fewer hospital visits, without change in the number of primary care visits (2.01 v 3.22). The total average costs for the groups were respectively £922 and £1070. Patients felt more able to cope with their condition. The intervention did not reduce quality of life and did not raise anxiety. The intervention group reported fewer symptom relapses, and 74% of the patient wanted to continue the system.CE analysis favoured self management over standard care. Standard care was associated with slightly better QALYs profile (QALYs gain of 0.00022) and an increase in cost per patient of £148. This is likely to be far in excess of values currently deemed acceptable to healthcare founders.The authors also estimated that the burden of IBD ranges between £75m and £85m a yearAn excellent study.Future research is recommended to evaluate the operating systems within secondary and primary care that would allow self managers to self refer and to keep them informed of new treatments, also to explore self care methods, to study long term effects of self management in chronic disease.There is little evidence on long term effects. This study looked at one year, but it is likely that significant morbidity and mortality effects will take several years to determine. There is a need to establish how well open access works over a long period and whether clinic and patients revert to a system of fixed appointments
Moayyedi et al777UK (1999)Discrete Choice Experiment354 Patients (mean age 47)Eliciting patient preferences for gastroenterology clinic reorganisationFour key attributes were identified: waiting time from the GP’s referral, waiting time in the clinic, consultation time with the specialist, and waiting time for the investigation.Our data suggest that patients value waiting for investigations as highly as time spent on a waiting list, as a reduction in either will lead to a more rapid diagnosis.Discrete Choice Experiment (DCE) is a technique recently introduced to ascertain patients’ preferences in the delivery of health care; hence, the results need to be confirmed by other studies