Targets and self monitoring in hypertension: randomised controlled trial and cost effectiveness analysis

OBJECTIVES: To assess whether blood pressure control in primary care could be improved with the use of patient held targets and self monitoring in a practice setting, and to assess the impact of these on health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences, and costs. DESIGN: Randomised controlled trial. SETTING: Eight general practices in south Birmingham. PARTICIPANTS: 441 people receiving treatment in primary care for hypertension but not controlled below the target of < 140/85 mm Hg. INTERVENTIONS: Patients in the intervention group received treatment targets along with facilities to measure their own blood pressure at their general practice; they were also asked to visit their general practitioner or practice nurse if their blood pressure was repeatedly above the target level. Patients in the control group received usual care (blood pressure monitoring by their practice). MAIN OUTCOME MEASURES: Primary outcome: change in systolic blood pressure at six months and one year in both intervention and control groups. Secondary outcomes: change in health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences of method of blood pressure monitoring, and costs. RESULTS: 400 (91%) patients attended follow up at one year. Systolic blood pressure in the intervention group had significantly reduced after six months (mean difference 4.3 mm Hg (95% confidence interval 0.8 mm Hg to 7.9 mm Hg)) but not after one year (mean difference 2.7 mm Hg (- 1.2 mm Hg to 6.6 mm Hg)). No overall difference was found in diastolic blood pressure, anxiety, health behaviours, or number of prescribed drugs. Patients who self monitored lost more weight than controls (as evidenced by a drop in body mass index), rated self monitoring above monitoring by a doctor or nurse, and consulted less often. Overall, self monitoring did not cost significantly more than usual care (251 pounds sterling (437 dollars; 364 euros) (95% confidence interval 233 pounds sterling to 275 pounds sterling) versus 240 pounds sterling (217 pounds sterling to 263 pounds sterling). CONCLUSIONS: Practice based self monitoring resulted in small but significant improvements of blood pressure at six months, which were not sustained after a year. Self monitoring was well received by patients, anxiety did not increase, and there was no appreciable additional cost. Practice based self monitoring is feasible and results in blood pressure control that is similar to that in usual care.

Bagging model with cost sensitive analysis on diabetes data

Diabetes patients might suffer from an unhealthy life, long-term treatment and chronic complicated diseases. The decreasing hospitalization rate is a crucial problem for health care centers. This study combines the bagging method with base classifier decision tree and costs-sensitive analysis for diabetes patients' classification purpose. Real patients' data collected from a regional hospital in Thailand were analyzed. The relevance factors were selected and used to construct base classifier decision tree models to classify diabetes and non-diabetes patients. The bagging method was then applied to improve accuracy. Finally, asymmetric classification cost matrices were used to give more alternative models for diabetes data analysis.

Information system planning in drug service:a case study

The development of an information system in Caribbean public sector organisations is usually seen as a matter of installing hardware and software according to a directive from senior management, without much planning. This causes huge investment in procuring hardware and software without improving overall system performance. Increasingly, Caribbean organisations are looking for assurances on information system performance before making investment decisions not only to satisfy the funding agencies, but also to be competitive in this dynamic and global business world. This study demonstrates an information system planning approach using a process-reengineering framework. Firstly, the stakeholders for the business functions are identified along with their relationships and requirements. Secondly, process reengineering is carried out to develop the system requirements. Accordingly, information technology is selected through detailed system requirement analysis. Thirdly, cost-benefit analysis, identification of critical success factors and risk analysis are carried out to strengthen the selection. The entire methodology has been demonstrated through an information system project in the Barbados drug service, a public sector organisation in the Caribbean.

Drug testing: a way to weed out users?

The aim of this paper is to provide managers and Human Resource executives with the basis for making drug testing policy in their organisations by presenting a critical review of existing literature on Workplace Drug Testing (WDT) and related areas which have been structured into the key areas.The key finding is whilst WDT is becoming more and more widely used, the rationale for this in terms of organizational effectiveness and safety is far from clear. Also there are significant ethical issues associated with WDT which are not always fully considered by organisations. Similarly, a cost/benefit analysis for particular organisations may well show little reason to embark on a testing policy. As a result of our review, we recommend that practitioners take a critical view of proposals introducing WDT since in many cases there is little upside to such a policy and a largely under-researched downside. There are also wider implications for society as a whole since the issue of drug taking as a whole is clearly a matter of great importance to practically every country in the world. The workplace is not at all immune from the impact of drug taking and perhaps a knee-jerk response by managers is to attempt to exclude anyone with any sort of drug habit through the use of WDT. This type of review with a specific HR focus has not been carried out before despite several calls for a more rational approach to the area.

An investigation of the retail marketing mix and its effectiveness in small shops

The recent history of small shop and independent retailing has been one of decline. The most desirable form of assistance is the provision of information which will increase the efficiency model of marketing mix effeciveness which may be applied in small scale retailing. A further aim is to enhance theoretical development in the marketing field. Recent changes in retailing have affected location, product range, pricing and promotion practices. Although a large number of variables representing aspects of the marketing mix may be identified, it is not possible, on the basis of currently available information, to quantify or rank them according to their effect on sales performance. In designing a suitable study a major issue is that of access to a suitable representative sample of small retailers. The publish nature of the retail activities involved facilitates the use of a novel observation approach to data collection. A cross-sectional survey research design was used focussing on a clustered random sample of greengrocers and gent's fashion outfitters in the West Midlands. Linear multiple regression was the main analytical technique. Powerful regression models were evolved for both types of retailing. For greengrocers the major influences on trade are pedestrian traffic and shelf display space. For gent's outfitters they are centrality-to-other shopping, advertising and shelf display space. The models may be utilised by retailers to determine the relative strength of marketing mix variables. The level of precision is not sufficient to permit cost benefit analysis. Comparison of the findings for the two distinct kinds of business studied suggests an overall model of marketing mix effectiveness might be based on frequency of purchase, homogeneity of the shopping environment, elasticity of demand and bulk characteristics of the good sold by a shop.

Microcomputers for civil engineering consultancy in developing countries

The civil engineering industry generally regards new methods and technology with a high amount of scepticism, preferring to use traditional and trusted methods. During the 1980s competition for civil engineering consultancy work in the world has become fierce. Halcrow recognised the need to maintain and improve their competitive edge over other consultants. The use of new technology in the form of microcomputers was seen to be one method to maintain and improve their repuation in the world. This thesis examines the role of microcomputers in civil engineering consultancy with particular reference to overseas projects. The involvement of civil engineers with computers, both past and present, has been investigated and a survey of the use of microcomputers by consultancies was carried out, the results are presented and analysed. A resume of the state-of-the-art of microcomputer technology was made. Various case studies were carried out in order to examine the feasibility of using microcomputers on overseas projects. One case study involved the examination of two projects in Bangladesh and is used to illustrate the requirements and problems encountered in such situations. Two programming applications were undertaken, a dynamic programming model of a single site reservoir and the simulation of the Bangladesh gas grid system. A cost-benefit analysis of a water resources project using microcomputers in the Aguan Valley, Honduras was carried out. Although the initial cost of microcomputers is often small, the overall costs can prove to be very high and are likely to exceed the costs of traditional computer methods. A planned approach for the use of microcomputers is essential in order to reap the expected benefits and recommendations for the implementation of such an approach are presented.

The effect of major roads upon the local economy:a study of industrial location and its effects

The economic effects of road building (beyond those accounted for in cost-benefit analysis) are not well understood. This thesis examines the issues surrounding those effects and attempts to clarify the relationship between road building and industrial location and to identify the effect on employment of that location. The literature reviewed leads to some doubt as to the efficacy of roads as an economic tool. A scries of interviews with representatives of business and property professionals in three areas adjacent to motorways is carried out. These covered the firms' location or relocation decisions, their production costs, transport needs and employment. The conclusions drawn echo the above statements based on reviewed literature: 1. There was a general lack of knowledge of transport within a firm despite subjects' very good understanding of the rest of the firms' operations. 2. The importance of major roads to the business location decision and its perceived importance to the operations of the firms was low. Property professionals sec roads as an effective marketing tool. 3. Firms have a tendency to shed labour upon relocation although this does not necessarily constitute a net loss of employment but a redistribution. Recommendations are made for further research.

State-of-the-art in integrated vehicle health management

Cranfield University in collaboration with The Boeing Company have set up a Centre of Excellence in IVHM on the University?s technology park. Sponsored by the East of England Development Agency (EEDA), the Centre carries out pre-competitive research and development of IVHM technologies for the benefit of industrial partners. In addition, the dedicated facilities and university staff provide an unparalleled educational environment for learning and applying IVHM technologies. Boeing is actively involved in the creation and work of the Centre through its enterprise-wide Phantom Works technology organization. This paper will describe the organisation and operation of the Centre and will illustrate its activities by describing a research project being carried out in the Centre. This project is a demonstration of an end to end IVHM system beginning with cost/benefit analysis and extending to maintenance, logistics and operations decision support.

Applying quantitative methods in the assessment of outcomes of pharmacotherapy of psoriasis

Healthcare providers and policy makers are faced with an ever-increasing number of medical publications. Searching for relevant information and keeping up to date with new research findings remains a constant challenge. It has been widely acknowledged that narrative reviews of the literature are susceptible to several types of bias and a systematic approach may protect against these biases. The aim of this thesis was to apply quantitative methods in the assessment of outcomes of topical therapies for psoriasis. In particular, to systematically examine the comparative efficacy, tolerability and cost-effectiveness of topical calcipotriol in the treatment of mild-to-moderate psoriasis. Over the years, a wide range of techniques have been used to evaluate the severity of psoriasis and the outcomes from treatment. This lack of standardisation complicates the direct comparison of results and ultimately the pooling of outcomes from different clinical trials. There is a clear requirement for more comprehensive tools for measuring drug efficacy and disease severity in psoriasis. Ideally, the outcome measures need to be simple, relevant, practical, and widely applicable, and the instruments should be reliable, valid and responsive. The results of the meta-analysis reported herein show that calcipotriol is an effective antipsoriatic agent. In the short-tenn, the pooled data found calcipotriol to be more effective than calcitriol, tacalcitol, coal tar and short-contact dithranol. Only potent corticosteroids appeared to have comparable efficacy, with less short-term side-effects. Potent corticosteroids also added to the antipsoriatic effect of calcipotriol, and appeared to suppress the occurrence of calcipotriol-induced irritation. There was insufficient evidence to support any large effects in favour of improvements in efficacy when calcipotriol is used in combination with systemic therapies in patients with severe psoriasis. However, there was a total absence of long-term morbidity data on the effectiveness of any of the interventions studied. Decision analysis showed that, from the perspective of the NHS as payer, the relatively small differences in efficacy between calcipotriol and short-contact dithranol lead to large differences in the direct cost of treating patients with mildto-moderate plaque psoriasis. Further research is needed to examine the clinical and economic issues affecting patients under treatment for psoriasis in the UK. In particular, the maintenance value and cost/benefit ratio for the various treatment strategies, and the assessment of patient's preferences has not yet been adequately addressed for this chronic recurring disease.

A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia:the ECLIPSE trial

BACKGROUND: Heavy menstrual bleeding (HMB) is a common problem, yet evidence to inform decisions about initial medical treatment is limited. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system (LNG-IUS) (Mirena(®), Bayer) compared with usual medical treatment, with exploration of women's perspectives on treatment. DESIGN: A pragmatic, multicentre randomised trial with an economic evaluation and a longitudinal qualitative study. SETTING: Women who presented in primary care. PARTICIPANTS: A total of 571 women with HMB. A purposeful sample of 27 women who were randomised or ineligible owing to treatment preference participated in semistructured face-to-face interviews around 2 and 12 months after commencing treatment. INTERVENTIONS: LNG-IUS or usual medical treatment (tranexamic acid, mefenamic acid, combined oestrogen-progestogen or progesterone alone). Women could subsequently swap or cease their allocated treatment. OUTCOME MEASURES: The primary outcome was the patient-reported score on the Menorrhagia Multi-Attribute Scale (MMAS) assessed over a 2-year period and then again at 5 years. Secondary outcomes included general quality of life (QoL), sexual activity, surgical intervention and safety. Data were analysed using iterative constant comparison. A state transition model-based cost-utility analysis was undertaken alongside the randomised trial. Quality-adjusted life-years (QALYs) were derived from the European Quality of Life-5 Dimensions (EQ-5D) and the Short Form questionnaire-6 Dimensions (SF-6D). The intention-to-treat analyses were reported as cost per QALY gained. Uncertainty was explored by conducting both deterministic and probabilistic sensitivity analyses. RESULTS: The MMAS total scores improved significantly in both groups at all time points, but were significantly greater for the LNG-IUS than for usual treatment [mean difference over 2 years was 13.4 points, 95% confidence interval (CI) 9.9 to 16.9 points; p < 0.001]. However, this difference between groups was reduced and no longer significant by 5 years (mean difference in scores 3.9 points, 95% CI -0.6 to 8.3 points; p = 0.09). By 5 years, only 47% of women had a LNG-IUS in place and 15% were still taking usual medical treatment. Five-year surgery rates were low, at 20%, and were similar, irrespective of initial treatments. There were no significant differences in serious adverse events between groups. Using the EQ-5D, at 2 years, the relative cost-effectiveness of the LNG-IUS compared with usual medical treatment was £1600 per QALY, which by 5 years was reduced to £114 per QALY. Using the SF-6D, usual medical treatment dominates the LNG-IUS. The qualitative findings show that women's experiences and expectations of medical treatments for HMB vary considerably and change over time. Women had high expectations of a prompt effect from medical treatments. CONCLUSIONS: The LNG-IUS, compared with usual medical therapies, resulted in greater improvement over 2 years in women's assessments of the effect of HMB on their daily routine, including work, social and family life, and psychological and physical well-being. At 5 years, the differences were no longer significant. A similar low proportion of women required surgical intervention in both groups. The LNG-IUS is cost-effective in both the short and medium term, using the method generally recommended by the National Institute for Health and Care Excellence. Using the alternative measures to value QoL will have a considerable impact on cost-effectiveness decisions. It will be important to explore the clinical and health-care trajectories of the ECLIPSE (clinical effectiveness and cost-effectiveness of levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia) trial participants to 10 years, by which time half of the cohort will have reached menopause. TRIAL REGISTRATION: Current Controlled Trials ISRCTN86566246. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 88. See the NIHR Journals Library website for further project information.

Knowledge maintenance and the frame problem

Knowledge maintenance is a major challenge for both knowledge management and the Semantic Web. Operating over the Semantic Web, there will be a network of collaborating agents, each with their own ontologies or knowledge bases. Change in the knowledge state of one agent may need to be propagated across a number of agents and their associated ontologies. The challenge is to decide how to propagate a change of knowledge state. The effects of a change in knowledge state cannot be known in advance, and so an agent cannot know who should be informed unless it adopts a simple ‘tell everyone – everything’ strategy. This situation is highly reminiscent of the classic Frame Problem in AI. We argue that for agent-based technologies to succeed, far greater attention must be given to creating an appropriate model for knowledge update. In a closed system, simple strategies are possible (e.g. ‘sleeping dog’ or ‘cheap test’ or even complete checking). However, in an open system where cause and effect are unpredictable, a coherent cost-benefit based model of agent interaction is essential. Otherwise, the effectiveness of every act of knowledge update/maintenance is brought into question.

Multiple attribute decision making approach to petroleum pipeline route selection

Petroleum pipelines are the nervous system of the oil industry, as this transports crude oil from sources to refineries and petroleum products from refineries to demand points. Therefore, the efficient operation of these pipelines determines the effectiveness of the entire business. Pipeline route selection plays a major role when designing an effective pipeline system, as the health of the pipeline depends on its terrain. The present practice of route selection for petroleum pipelines is governed by factors such as the shortest distance, constructability, minimal effects on the environment, and approachability. Although this reduces capital expenditure, it often proves to be uneconomical when life cycle costing is considered. This study presents a route selection model with the application of an Analytic Hierarchy Process (AHP), a multiple attribute decision making technique. AHP considers all the above factors along with the operability and maintainability factors interactively. This system has been demonstrated here through a case study of pipeline route selection, from an Indian perspective. A cost-benefit comparison of the shortest route (conventionally selected) and optimal route establishes the effectiveness of the model.

The optimum prepaid monetary incentives for mail surveys

Increasing mail-survey response using monetary incentives is a proven, but not always cost-effective method in every population. This paper tackles the questions of whether it is worth using monetary incentives and the size of the inducement by testing a logit model of the impact of prepaid monetary incentives on response rates in consumer and organizational mail surveys. The results support their use and show that the inducement value makes a significant impact on the effect size. Importantly, no significant differences were found between consumer and organizational populations. A cost-benefit model is developed to estimate the optimum incentive when attempting to minimize overall survey costs for a given sample size. © 2006 Operational Research Society Ltd. All rights reserved.

Profitability of a sample of Portuguese bank branches and its decomposition into technical and allocative components

The efficiency literature, both using parametric and non-parametric methods, has been focusing mainly on cost efficiency analysis rather than on profit efficiency. In for-profit organisations, however, the measurement of profit efficiency and its decomposition into technical and allocative efficiency is particularly relevant. In this paper a newly developed method is used to measure profit efficiency and to identify the sources of any shortfall in profitability (technical and/or allocative inefficiency). The method is applied to a set of Portuguese bank branches first assuming long run and then a short run profit maximisation objective. In the long run most of the scope for profit improvement of bank branches is by becoming more allocatively efficient. In the short run most of profit gain can be realised through higher technical efficiency. © 2003 Elsevier B.V. All rights reserved.

Technology transfer to developing countries : the case of physical asset management in South Africa

This research investigates technology transfer (TT) to developing countries, with specific reference to South Africa. Particular attention is paid to physical asset management, which includes the maintenance of plant, equipment and facilities. The research is case based, comprising a main case study (the South African electricity utility, Eskom) and four mini-cases. A five level framework adapted from Salami and Reavill (1997) is used as the methodological basis for the formulation of the research questions. This deals with technology selection, and management issues including implementation and maintenance and evaluation and modifications. The findings suggest the Salami and Reavill (1997) framework is a useful guide for TT. The case organisations did not introduce technology for strategic advantage, but to achieve operational efficiencies through cost reduction, higher quality and the ability to meet customer demand. Acquirers favour standardised technologies with which they are familiar. Cost-benefit evaluations have limited use in technology acquisition decisions. Users rely on supplier expertise to compensate for poor education and technical training in South Africa. The impact of political and economic factors is more evident in Eskom than in the mini-cases. Physical asset management follows traditional preventive maintenance practices, with limited use of new maintenance management thinking. Few modifications of the technology or R&D innovations take place. Little use is made of explicit knowledge from computerised maintenance management systems. Low operating and maintenance skills are not conducive to the transfer of high-technology equipment. South African organisations acquire technology as items of plant, equipment and systems, but limited transfer of technology takes place. This suggests that operators and maintainers frequently do not understand the underlying technology, and like workers elsewhere, are not always inclined towards adopting technology in the workplace.