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

Authors	Research setting and year of study	Study design	Sample size	Topic of document	Results and conclusions	Comments
Association of Coloproctology of Great Britain and Ireland753	UK (2000)	Postal survey	Replies from 75 centres covering 26.5 million	The number of staff needed for coloproctology	Extra 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 nurses	A good mapping of needs; it does deal with the most cost effective ways to reach the target
South Wales Cancer Network754	UK (Wales) (2002)	Review	NA	Service development plan	By 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 guidelines	Mainly a research agenda document
Guillou et al776	UK (1996)	Review	NA	Minimal access GI surgery	Evidence on cost effectiveness of laporoscopic v conventional cholesystectomy too thin to report	Most evidence is from the USA, where charges rather than costs are used. Authors (quite rightly) warn about this
MacKenzie et al597	UK (1999–2001)	RCT	552 Intervention group; 565 control Group	Method of investigating large bowel symptoms	NHS 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 significant	SD and ranges of cost figures were not reported. Further research is required to identify the reasons for non‐attendance
Bowles et al752	UK (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 regions	There 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 course	The study did not include an economic component
Burling et al755	UK (2003)	Observational study	138 Departments	The provision of CT colonography in UK radiology departments	CT 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 dissemination	The 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 al756	UK (1998–99)	Prospective population based survey	739 new IBD cases across 3247 paediatricians, adult gastroenterologists, and surgeons in the UK	Variation in the management of children with newly diagnosed IBD	This 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 heterogeneous	There is no economic analysis
Kennedy et al683	UK (2003)	RCT	700 Patients (297 intervention, 403, control) across 19 hospitals in northwest England	Explore 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 IBD	After 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 year	An 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 al777	UK (1999)	Discrete Choice Experiment	354 Patients (mean age 47)	Eliciting patient preferences for gastroenterology clinic reorganisation	Four 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