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Rapid Responses: Rapid Responses published:
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Open access care for imflammatory bowel disease: implications for future studies
- Rowena Yates (2 March 2000)
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Open Access Follow up for Inflammatory Bowel Disease
- Aravinthan Coomarasamy (17 March 2000)
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OPEN ACCESS VERSUS ROUTINE FOLLOW UP: WHAT ABOUT ACCIDENT AND EMERGENCY CARE?
- O O Jibuike (18 March 2000)
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Rowena Yates, 3rd Year medical student Department of Epidemiology & Public Health, University of Newcastle Upon Tyne
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Dear Editor, Williams et al raise some important questions regarding the effectiveness of open access follow-up care for patients with inflammatory bowel disease. They conclude that open access follow-up delivered the same quality of care as routine out-patient appointments and is preferred by patients and general practitioners, without significantly affecting total resource use. Their conclusions apply only to patients with mild or inactive disease, yet they do not emphasise this sufficiently or mention it in their abstract. Their unexplained exclusion of 43 patients with active disease requiring treatment limits the power and significance of the study and its applicability to clinical practice. We argue that such patients are vital to this study as they may be those who use most resources. Although they acknowledge the study is under-powered, the confidence intervals for differences in quality of life scores are compatible with both marked deterioration and improvement, undermining the conclusions of the study. We were uncertain about their subjective judgement regarding exclusion of 10 patients who were thought "unable to comply with data collection". We support the evaluation of resource use and measurement of patient and GP satisfaction. We recommend that future research should include patients with active disease and that sample size should be increased to allow valid conclusions to be drawn. Yours sincerely, Rowena Yates, Ashleigh Willins, Louise Roberts, Aylwin Chick. Stage 3 Medical Students, Department of Epidemiology and Public Health, the Medical School, University of Newcastle Upon Tyne. |
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Aravinthan Coomarasamy
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Editor- A very important clinical outcome of risk of cancer development was not addressed in this paper. The sample size would have had to be much larger and the study conducted for a much longer period for it to have the power to pick up such a rare event. Nevertheless development of cancer is a very important outcome and without knowing whether pick up of such event would be adversely affected by the open access policy, it would not be prudent to recommend this strategy whole-heartedly. The authors offer the suggestion of a nurse practitioner calling patients at regular intervals for assessment and colonoscopy if necessary to reduce the risk of gastrointestinal malignancy, but in that case they should have included the cost of hiring, training, housing and sustaining such staff in the cost considerations(2). In an economic analysis it is important to consider all the costs as well as outcomes. Medical staff abstracted data from hospital notes and 'practice staff' from GP records. Who were the practice staff? Were they general practitioners, clerical staff, receptionists or a varying combination? The quality and consistency of the data obtained would vary depending on who abstracted it. We were puzzled by the statement that 'semi-structured interviews were undertaken by general practitioners during audit visits to "minimise bias"'. An independent blinded interviewer would eliminate or reduce bias, a general practitioner is unlikely to. We were disappointed to note that sensitivity analysis was not performed as this is an important part of any cost-effective analysis. As disease specific questionnaire was not validated it would not be valid to draw any conclusion from this, yet the table on quality of life comparison (table1 in the original article) was interesting in that although all results were not statistically significant, there was a clear trend with negative numbers predominating the table indicating a 'better change' in the routine follow up patients compared to open access patients. This brings up the question if the statistical non-significance was due to lack of power of the study to pick up a true difference when one existed. Given these weaknesses, we feel it would not be appropriate to recommend open access strategy other than in the setting of further more powerful and longer study to answer these clearly important issues. A Coomarasamy
D Van
Der Berg 1. Open access follow up for inflammatory bowel disease: pragmatic randomised trial and cost effectiveness study. J G Williams, W Y Cheung, I T Russell, D R Cohen, M Longo, B Lervy BMJ 2000;320:542-548 2. Evidence-based and Cost-effective Medicine, Tony Lockett 1997, Radcliffe Medical Press |
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O O Jibuike, Specialist Registrar Emergency Unit University Hospital of Wales, Cardiff.
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OPEN ACCESS VERSUS ROUTINE FOLLOW UP: PRIMARY AND SECONDARY CARES. WHAT ABOUT ACCIDENT AND EMERGENCY CARE? The article by Williams et al was quite innovative and interesting. They measured some of the outcomes for primary and ‘secondary’ contacts of inflammatory bowel disease sufferers, estimated ‘total’ resource use and views of patients and General Practitioners.1. What about the outcome, resources use and view of emergency physicians? Accident and Emergency Medicine is an interface between primary and secondary care and is resource intensive. Therefore most conditions that affect primary and secondary cares have knock on effects on accident and emergency (A&E) departments. For a condition such as inflammatory bowel disease whose stability is unpredictable, and whose remissions and relapses are also changeable, surely a significant proportion must have turned out at local A&E departments. This has resource implications for the emergency units at Swansea and Neath. Health economists have long established that a cost is a cost no matter who bears it2. In this connection, the cost effectiveness analysis omitted the cost analysis of resources utilised at the local emergency units. The views of A&E physicians in the locality were also disregarded as a consequence. Analysis of admissions into University Hospital of Wales, Cardiff from the Emergency Unit (EU) in its first 9 months of operation at the new site has shown that 18% of admissions were avoided in the specialities of Medicine, Surgery and Urology in patients who attend the Assessment Unit of the EU3. As these were not in-patients resources utilised would be inadvertently omitted in the analysis. Time is one of the most expensive resources in A&E4. Some patients especially in the open access arm must have rang the local A&E for advice especially as some had difficulty obtaining an urgent outpatient appointment. This again impacts on the workload of A&E which was not taken into account in the study. This could be why the mean total cost in secondary care was lower for open access patients. Such omissions run the risk of reducing a cost-effective study to a cost and consequences study. I believe the inclusion of costs and preferences of emergency physicians in the cost effectiveness analysis of this nature are vital component of the economic appraisal. Yours Sincerely, O.O.Jibuike. Specialist Registrar Emergency Unit, University Hospital of Wales Cardiff. REFENCES 1. Williams,J. G., Cheung, W. Y., Russell, I. T., Cohen, D. R., Longo, M., Lervy, B. Open Access Follow up for Inflammatory Bowel Disease: Pragmatic randomised trial and cost effectiveness study. Br Med J 2000: 544-548. 2. Drummond, M., O’Brien, B., Stoddart, G. and Torrance, G. Cost Analysis in Methods for the Economic Evaluation of Programmes in Health Care. 2nd edition. Oxford, Oxford University Press: 52 – 87. 3. Richmond, P., Rees-Evans, B., Simmons, R., Banton S. Emergency Unit The First Nine Months. Activity - Analysis and Comment January 2000 University Hospital of Wales, Cardiff: 1 4. BAEM (British Association of Accident and Emergency Medicine) Report of the Working Party on The Way Ahead 1998. London, British Association of Accident and Emergency Medicine |
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