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Objectives: To assess the cost-effectiveness of optometrist-led follow-up monitoring reviews for patients with quiescent neovascular age-related macular degeneration (nAMD) in community settings (including high street opticians) compared with ophthalmologist-led reviews in hospitals. Design: A model-based cost-effectiveness analysis with a 4-week time horizon, based on a 'virtual' noninferiority randomised trial designed to emulate a parallel group design. Setting: A virtual internet-based clinical assessment, conducted at community optometry practices, and hospital ophthalmology clinics. Participants: Ophthalmologists with experience in the age-related macular degeneration service; fully qualified optometrists not participating in nAMD shared care schemes. Interventions: The participating optometrists and ophthalmologists classified lesions from vignettes and were asked to judge whether any retreatment was required. Vignettes comprised clinical information, colour fundus photographs and optical coherence tomography images. Participants' classifications were validated against experts' classifications (reference standard). Resource use and cost information were attributed to these retreatment decisions. Main outcome measures: Correct classification of whether further treatment is needed, compared with a reference standard. Results: The mean cost per assessment, including the subsequent care pathway, was £411 for optometrists and £397 for ophthalmologists: a cost difference of £13 (95% CI -£18 to £45). Optometrists were noninferior to ophthalmologists with respect to the overall percentage of lesions correctly assessed (difference -1.0%; 95% CI -4.5% to 2.5%). Conclusions: In the base case analysis, the slightly larger number of incorrect retreatment decisions by optometrists led to marginally and non-significantly higher costs. Sensitivity analyses that reflected different practices across eye hospitals indicate that shared care pathways between optometrists and ophthalmologists can be identified which may reduce demands on scant hospital resources, although in light of the uncertainty around differences in outcome and cost it remains unclear whether the differences between the 2 care pathways are significant in economic terms. [ABSTRACT FROM AUTHOR]

Objective: To assess the incremental cost and costeffectiveness of a restrictive versus a liberal red blood cell transfusion threshold after cardiac surgery. Design: A within-trial cost-effectiveness analysis with a 3-month time horizon, based on a multicentre superiority randomised controlled trial from the perspective of the National Health Service (NHS) and personal social services in the UK. Setting: 17 specialist cardiac surgery centres in UK NHS hospitals. Participants:2003 patients aged >16 years undergoing non-emergency cardiac surgery with a postoperative haemoglobin of <9 g/dL. Interventions: Restrictive (transfuse if haemoglobin <7.5 g/dL) or liberal (transfuse if haemoglobin <9 g/dL) threshold during hospitalisation after surgery. Main outcome measures: Health-related quality of life measured using the EQ-5D-3L to calculate qualityadjusted life years (QALYs). Results: The total costs from surgery up to 3 months were £17 945 and £18 127 in the restrictive and liberal groups (mean difference is -£182, 95% CI -£1108 to £744). The cost difference was largely attributable to the difference in the cost of red blood cells. Mean QALYs to 3months were 0.18 in both groups (restrictive minus liberal difference is 0.0004, 95% CI -0.0037 to 0.0045). The point estimate for the base-case costeffectiveness analysis suggested that the restrictive group was slightly more effective and slightly less costly than the liberal group and, therefore, cost-effective. However, there is great uncertainty around these results partly due to the negligible differences in QALYs gained. Conclusions: We conclude that there is no clear difference in the cost-effectiveness of restrictive and liberal thresholds for red blood cell transfusion after cardiac surgery. [ABSTRACT FROM AUTHOR]

Background: Somatic mutations are important determinants of cancer behaviour and response to therapy. However, molecular testing in this context has a relatively low profile within the clinical community, despite publicity surrounding targeted therapies such as Herceptin. Aims: As the testing process affects many stakeholders, especially oncologists, this paper examines current test request patterns and views of such testing. Methods: A postal questionnaire was mailed to 582 UK oncologists and haematologists, achieving a 20% response rate. Results: The survey revealed that immunohistochemistry and fluorescent in situ hybridisation are the most commonly requested tests (used by 70% and 55% of respondents, respectively), especially for breast cancer. Availability of suitable treatment options is the main factor influencing the decision to test (selected by 62% of respondents). Respondents were generally positive about future demand for immunohistochemistry, fluorescent in situ hybridisation, microarray analysis and DNA-based tests, but uncertain about the prospects for microsatellite instability and ploidy testing. Conclusions: Overall, respondents thought that somatic mutation testing could have a significant and positive effect on oncology and haematology departments and patient care, especially with better treatment and tumour classification. However, lack of supportive scientific evidence and funding were considered key barriers to widespread testing. Further research is clearly required on both the resource implications of this increase in demand and the best model of service delivery to ensure the most efficient use of health service resources. [ABSTRACT FROM AUTHOR]

Background: Genetics clinical practice has paid limited attention to non-inherited aspects of cancer, namely mutations occurring during carcinogenesis. These somatic mutations are likely to be the primary determinants of cancer behaviour and treatment response, with a recent example being Her2/Neu gene status and response to Herceptin in breast cancer. Aim: To assess the feasibility of widespread testing of tumours by surveying UK histopathology and genetics laboratories. Methods: The questionnaire asked: which of the common cancers or other malignancies are routinely assessed; which molecular and cytogenetic methods are used; who orders and funds testing; what is the future demand for somatic testing; and what are the barriers to widespread testing? Results: Of 50 laboratories surveyed, 33 responded, 22 of which are currently using molecular tests. The survey shows that the most common tests are immunohisto-chemistry fluorescence in-situ hybridisation and DNA testing of somatic mutations. Most laboratories predict testing will increase over the next 10 years, particularly for DNA testing using microarrays. Respondents perceived the main barriers to expanding molecular testing were a lack of laboratory funding and scientific evidence and testing not considered an NHS priority. Conclusion: These results provide important information for healthcare commissioners faced with managing demand for molecular testing of cancers. [ABSTRACT FROM AUTHOR]