Imperial College London


Faculty of MedicineDepartment of Surgery & Cancer

Research Postgraduate







Queen Elizabeth the Queen Mother Wing (QEQM)St Mary's Campus





Publication Type

14 results found

Dilley J, Camara M, Omar I, Carter A, Pratt P, Vale J, Darzi A, Mayer EKet al., 2019, Evaluating the impact of image guidance in the surgical setting: A systematic review, Surgical Endoscopy, Vol: 33, Pages: 2785-2793, ISSN: 0930-2794

BACKGROUND: Image guidance has been clinically available for over a period of 20 years. Although research increasingly has a translational emphasis, overall the clinical uptake of image guidance systems in surgery remains low. The objective of this review was to establish the metrics used to report on the impact of surgical image guidance systems used in a clinical setting. METHODS: A systematic review of the literature was carried out on all relevant publications between January 2000 and April 2016. Ovid MEDLINE and Embase databases were searched using a title strategy. Reported outcome metrics were grouped into clinically relevant domains and subsequent sub-categories for analysis. RESULTS: In total, 232 publications were eligible for inclusion. Analysis showed that clinical outcomes and system interaction were consistently reported. However, metrics focusing on surgeon, patient and economic impact were reported less often. No increase in the quality of reporting was observed during the study time period, associated with study design, or when the clinical setting involved a surgical specialty that had been using image guidance for longer. CONCLUSIONS: Publications reporting on the clinical use of image guidance systems are evaluating traditional surgical outcomes and neglecting important human and economic factors, which are pertinent to the uptake, diffusion and sustainability of image-guided surgery. A framework is proposed to assist researchers in providing comprehensive evaluation metrics, which should also be considered in the design phase. Use of these would help demonstrate the impact in the clinical setting leading to increased clinical integration of image guidance systems.

Journal article

Grant Y, Al-Khudairi R, St John E, Barschkett M, Cunningham D, Al-Mufti R, Hogben K, Thiruchelvam P, Hadjiminas DJ, Darzi A, Carter AW, Leff DRet al., 2019, Patient-level costs in margin re-excision for breast-conserving surgery, British Journal of Surgery, Vol: 106, Pages: 384-394, ISSN: 1365-2168

BackgroundHigh rates of reoperation following breast‐conserving surgery (BCS) for positive margins are associated with costs to healthcare providers. The aim was to assess the quality of evidence on reported re‐excision costs and compare the direct patient‐level costs between patients undergoing successful BCS versus reoperations after BCS.MethodsThe study used data from women who had BCS with or without reoperation at a single institution between April 2015 and March 2016. A systematic review of health economic analysis in BCS was conducted and scored using the Quality of Health Economic Studies (QHES) instrument. Financial data were retrieved using the Patient‐Level Information and Costing Systems (PLICS) for patients. Exchange rates used were: US $1 = £0·75, £1 = €1·14 and US $1 = €0·85.ResultsThe median QHES score was 47 (i.q.r. 32·5–79). Only two of nine studies scored in the upper QHES quartile (score at least 75). Costs of initial lumpectomy and reoperation were in the range US $1234–11786 and $655–9136 respectively. Over a 12‐month interval, 153 patients had definitive BCS and 59 patients underwent reoperation. The median cost of reoperations after BCS (59 patients) was £4511 (range 1752–18 019), representing an additional £2136 per patient compared with BCS without reoperation (P < 0·001).ConclusionThe systematic review demonstrated variation in methodological approach to cost estimates and a paucity of high‐quality cost estimate studies for reoperations. Extrapolating local PLICS data to a national level suggests that getting BCS right first time could result in substantial savings.

Journal article

Mandavia R, Knight A, Carter AW, Toal C, Mossialos E, Littlejohns P, Schilder AGMet al., 2018, What are the requirements for developing a successful national registry of auditory implants? A qualitative study, BMJ OPEN, Vol: 8, ISSN: 2044-6055

Journal article

Neves AL, Carter AW, Freise L, Laranjo L, Darzi A, Mayer EKet al., 2018, Impact of sharing electronic health records with patients on the quality and safety of care: a systematic review and narrative synthesis protocol, BMJ Open, Vol: 8, ISSN: 2044-6055

Introduction: Providing patients with access to electronic health records (EHRs) has emerged as a promising solution to improve quality of care and safety. As the efforts to develop and implement EHR-based data sharing platforms mature and scale up worldwide, there is a need to evaluate the impact of these interventions and to weigh their relative risks and benefits, in order to inform evidence-based health policies. The aim of this work is to systematically characterise and appraise the demonstrated benefits and risks of sharing EHR with patients, by mapping them across the six domains of quality of care of the Institute of Medicine (IOM) analytical framework (ie, patient-centredness, effectiveness, efficiency, timeliness, equity and safety).Methods and analysis: CINAHL, Cochrane, Embase, HMIC, Medline/PubMed and PsycINFO databases will be searched from January 1997 to August 2017. Primary outcomes will include measures related with the six domains of quality of care of the IOM analytical framework. The quality of the studies will be assessed using the Cochrane Risk of Bias Tool, the ROBINS-I Tool and the Drummond’s checklist. A narrative synthesis will be conducted for all included studies. Subgroup analysis will be performed by domain of quality of care domain and by time scale (ie, short-term, medium-term or long-term impact). The body of evidence will be summarised in a Summary of Findings table and its strength assessed according to the GRADE criteria.Ethics and dissemination: This review does not require ethical approval as it will summarise published studies with non-identifiable data. This protocol complies with the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols guidelines. Findings will be disseminated widely through peer-reviewed publication and conference presentations, and patient partners will be included in summarising the research findings into lay summaries and reports.PROSPERO registration number: CRD42017070092.

Journal article

bhatti Y, taylor A, harris M, wadge H, escobar E, prime M, patel H, carter A, parston G, darzi Aet al., 2017, Global Lessons In Frugal Innovation To Improve Health Care Delivery In The United States, Health Affairs, Vol: 36, Pages: 1912-1919, ISSN: 0278-2715

In a 2015 global study of low-cost or frugal innovations, we identified five leading innovations that scaled successfully in their original contexts and that may provide insights for scaling such innovations in the United States. We describe common themes among these diverse innovations, critical factors for their translation to the United States to improve the efficiency and quality of health care, and lessons for the implementation and scaling of other innovations. We highlight promising trends in the United States that support adapting these innovations, including growing interest in moving care out of health care facilities and into community and home settings; the growth of alternative payment models and incentives to experiment with new approaches to population health and care delivery; and the increasing use of diverse health professionals, such as community health workers and advanced practice providers. Our findings should inspire policy makers and health care professionals and inform them about the potential for globally sourced frugal innovations to benefit US health care.

Journal article

Bhatti Y, Prime M, Harris M, Wadge H, McQueen J, Patel H, Carter A, Parston G, Darzi Aet al., 2017, The search for the Holy Grail -- frugal innovation in healthcare from developing countries for reverse innovation to developed countries, BMJ Innovations, Vol: 3, Pages: 212-220, ISSN: 2055-642X

The healthcare sector stands to benefit most from frugal innovation, the idea that more can be done for less for many more people, globally. As a first step for health systems to leverage new approaches to offset escalating health expenditures and to improve health outcomes, the most relevant frugal innovations have to be found. The Institute of Global Health Innovation was commissioned by the US-based Commonwealth Fund to identify frugal innovations from around the world that could, if transferred to the USA, offer approaches for expanding access to care and dramatically lower costs. Our global scan was motivated by the need to extend the list of frugal innovations in healthcare beyond the impressive but oft-repeated examples such as GE’s MAC 400, a US$800 portable ECG machine, Narayana’s US$1500 cardiac surgery and Aravind’s US$30 cataract surgery. Our search involved (1) scanning innovation databases, (2) refining frameworks to identify frugal innovations and evaluate their reverse potential and (3) developing in-depth case studies. From 520 possible innovations, we shortlisted 16 frugal innovations that we considered as frugal and with potential for reverse diffusion into high-income country health systems. Our global search was narrowed down to three care delivery models for case analysis: The Brazilian Family Health Strategy around community health workers; Singapore-based GeriCare@North use of telemedicine and Brazil’s Saude Crianca community involvement and citizenship programme. We share core features of the three frugal innovations and outline lessons for practitioners, scholars and policymakers seeking to lower healthcare costs while increasing access and quality.

Journal article

Neves AL, Roy R, Wadge H, Fugard A, Freise L, Carter A, Mayer Eet al., 2017, A framework for evaluating the economic impact of EHR-based interventions


Mandavia R, Carter AW, Haram N, Mossialos E, Schilder AGMet al., 2017, An evaluation of the quality of evidence available to inform current bone conducting hearing device national policy, CLINICAL OTOLARYNGOLOGY, Vol: 42, Pages: 1000-1024, ISSN: 1749-4478

Journal article

Carter AW, Mandavia R, Mayer E, Marti J, Mossialos E, Darzi Aet al., 2017, Systematic review of economic analyses in patient safety: a protocol designed to measure development in the scope and quality of evidence., BMJ Open, Vol: 7, ISSN: 2044-6055

INTRODUCTION: Recent avoidable failures in patient care highlight the ongoing need for evidence to support improvements in patient safety. According to the most recent reviews, there is a dearth of economic evidence related to patient safety. These reviews characterise an evidence gap in terms of the scope and quality of evidence available to support resource allocation decisions. This protocol is designed to update and improve on the reviews previously conducted to determine the extent of methodological progress in economic analyses in patient safety. METHODS AND ANALYSIS: A broad search strategy with two core themes for original research (excluding opinion pieces and systematic reviews) in 'patient safety' and 'economic analyses' has been developed. Medline, Econlit and National Health Service Economic Evaluation Database bibliographic databases will be searched from January 2007 using a combination of medical subject headings terms and research-derived search terms (see table 1). The method is informed by previous reviews on this topic, published in 2012. Screening, risk of bias assessment (using the Cochrane collaboration tool) and economic evaluation quality assessment (using the Drummond checklist) will be conducted by two independent reviewers, with arbitration by a third reviewer as needed. Studies with a low risk of bias will be assessed using the Drummond checklist. High-quality economic evaluations are those that score >20/35. A qualitative synthesis of evidence will be performed using a data collection tool to capture the study design(s) employed, population(s), setting(s), disease area(s), intervention(s) and outcome(s) studied. Methodological quality scores will be compared with previous reviews where possible. Effect size(s) and estimate uncertainty will be captured and used in a quantitative synthesis of high-quality evidence, where possible. ETHICS AND DISSEMINATION: Formal ethical approval is not required as primary data will not be collected. T

Journal article

Orlovic M, Carter AW, Marti J, Mossialos Eet al., 2017, Estimating the incidence and the economic burden of third and fourth-degree obstetric tears in the English NHS: an observational study using propensity score matching, BMJ Open, Vol: 7, ISSN: 2044-6055

Objective Obstetric care is a high-risk area in healthcaredelivery, so it is essential to have up-to-date quantitativeevidence in this area to inform policy decisions regardingthese services. In light of this, the objective of this studyis to investigate the incidence and economic burden ofthird and fourth-degree lacerations in the English NationalHealth Service (NHS) using recent national data.Methods We used coded inpatient data from HospitalEpisode Statistics (HES) for the financial years from2010/2011 to 2013/2014 for all females that gave birthduring that period in the English NHS. Using HES, we usedpre-existing safety indicator algorithms to calculate theincidence of third and fourth-degree obstetric tears andemployed a propensity score matching method to estimatethe excess length of stay and economic burden associatedwith these events.Results Observed rates per 1000 inpatient episodes in2010/2011 and 2013/2014, respectively: Patient SafetyIndicator—trauma during vaginal delivery with instrument(PSI 18)=84.16 and 91.24; trauma during vaginaldelivery without instrument (PSI 19)=29.78 and 33.43;trauma during caesarean delivery (PSI 20)=3.61 and4.56. Estimated overall (all PSIs) economic burden for2010/2011=£10.7 million and for 2013/2014=£14.5million, expressed in 2013/2014 prices.Conclusions Despite many initiatives targeting thequality of maternity care in the NHS, the incidence of thirdand fourth-degree lacerations has increased during theobserved period which signals that quality improvementefforts in obstetric care may not be reducing incidencerates. Our conservative estimates of the financial burden ofthese events appear low relative to total NHS expenditurefor these years.

Journal article

Sabharwal S, Carter AW, Rashid A, Darzi A, Reilly P, Gupte CMet al., 2016, Cost analysis of the surgical treatment of fractures of the proximal humerus: an evaluation of the determinants of cost and comparison of the institutional cost of treatment with the national tariff, Bone & Joint Journal, Vol: 98B, Pages: 249-259, ISSN: 2049-4394

Aims The aims of this study were to estimate the cost of surgical treatment of fractures of the proximal humerus using a micro-costing methodology, contrast this cost with the national reimbursement tariff and establish the major determinants of cost.Methods A detailed inpatient treatment pathway was constructed using semi-structured interviews with 32 members of hospital staff. Its content validity was established through a Delphi panel evaluation. Costs were calculated using time-driven activity-based costing (TDABC) and sensitivity analysis was performed to evaluate the determinants of costResults The mean cost of the different surgical treatments was estimated to be £3282. Although this represented a profit of £1138 against the national tariff, hemiarthroplasty as a treatment choice resulted in a net loss of £952. Choice of implant and theatre staffing were the largest cost drivers. Operating theatre delays of more than one hour resulted in a loss of incomeDiscussion Our findings indicate that the national tariff does not accurately represent the cost of treatment for this condition. Effective use of the operating theatre and implant discounting are likely to be more effective cost containment approaches than control of bed-day costs.Take home message: This cost analysis of fractures of the proximal humerus reinforces the limitations of the national tariff within the English National Health Service, and underlines the importance of effective use of the operating theatre, as well as appropriate implant procurement where controlling costs of treatment is concerned.

Journal article

Naci H, Carter AW, Mossialos E, 2015, Why the drug development pipeline is not delivering better medicines, BMJ-BRITISH MEDICAL JOURNAL, Vol: 351, ISSN: 1756-1833

Despite the large number of new medicines entering the market every year, few offer importantclinical advantages for patients. Huseyin Naci, Alexander Carter, and Elias Mossialos explainthe reasons for this innovation deficit and offer some solutions

Journal article

Carter AW, Mossialos E, Darzi A, 2015, A national incident reporting and learning system in England and Wales, but at what cost?, EXPERT REVIEW OF PHARMACOECONOMICS & OUTCOMES RESEARCH, Vol: 15, Pages: 365-368, ISSN: 1473-7167

Journal article

Sabharwal S, Carter A, Darzi LA, Reilly P, Gupte CMet al., 2015, The methodological quality of health economic evaluations for the management of hip fractures: A systematic review of the literature, SURGEON-JOURNAL OF THE ROYAL COLLEGES OF SURGEONS OF EDINBURGH AND IRELAND, Vol: 13, Pages: 170-176, ISSN: 1479-666X

Background and objectivesApproximately 76,000 people a year sustain a hip fracture in the UK and the estimated cost to the NHS is £1.4 billion a year. Health economic evaluations (HEEs) are one of the methods employed by decision makers to deliver healthcare policy supported by clinical and economic evidence. The objective of this study was to (1) identify and characterize HEEs for the management of patients with hip fractures, and (2) examine their methodological quality.MethodsA literature search was performed in MEDLINE, EMBASE and the NHS Economic Evaluation Database. Studies that met the specified definition for a HEE and evaluated hip fracture management were included. Methodological quality was assessed using the Consensus on Health Economic Criteria (CHEC).ResultsTwenty-seven publications met the inclusion criteria of this study and were included in our descriptive and methodological analysis. Domains of methodology that performed poorly included use of an appropriate time horizon (66.7% of studies), incremental analysis of costs and outcomes (63%), future discounting (44.4%), sensitivity analysis (40.7%), declaration of conflicts of interest (37%) and discussion of ethical considerations (29.6%).ConclusionsHEEs for patients with hip fractures are increasing in publication in recent years. Most of these studies fail to adopt a societal perspective and key aspects of their methodology are poor. The development of future HEEs in this field must adhere to established principles of methodology, so that better quality research can be used to inform health policy on the management of patients with a hip fracture.

Journal article

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