Whilst significant advances have been made in persuading clinical researchers of the value of conducting economic evaluation alongside clinical trials, a number of problems remain. The most fundamental is the fact that economic principles are almost entirely ignored in the traditional approach to trial design. For example, in the selection of an optimal sample size no consideration is given to the marginal costs or benefits of sample information. In the traditional approach this can lead to either unbounded or arbitrary sample sizes. This paper presents a decision-analytic approach to trial design which takes explicit account of the costs of sampling, the benefits of sample information and the decision rules of cost-effectiveness analysis. It also provides a consistent framework for setting priorities in research funding and establishes a set of screens (or hurdles) to evaluate the potential cost-effectiveness of research proposals. The framework permits research priority setting based explicitly on the budget constraint faced by clinical practitioners and on the information available prior to prospective research. It demonstrates the link between the value of clinical research and the budgetary restrictions on service provision, and it provides practical tools to establish the optimal allocation of resources between areas of clinical research or between service provision and research.

Objective To examine the daily bed requirements arising from the flow of emergency admissions to an acute hospital, to identify the implications of fluctuating and unpredictable demands for emergency admission for the management of hospital bed capacity, and to quantify the daily risk of insufficient capacity for patients requiring immediate admission. Design Modelling of the dynamics of the hospital system, using a discrete-event stochastic simulation model, which reflects the relation between demand and available bed capacity. Setting Hypothetical acute hospital in England. Subjects Simulated emergency admissions of all types except mental disorder. Main outcome measures The risk of having no bed available for any patient requiring immediate admission; the daily risk that there is no bed available for at least one patient requiring immediate admission; the mean bed occupancy rate. Results Risks are discernible when average bed occupancy rates exceed about 85%, and an acute hospital can expect regular bed shortages and periodic bed crises if average bed occupancy rises to 90% or more. Conclusions There are limits to the occupancy rates that can be achieved safely without considerable risk to patients and to the efficient delivery of emergency care. Spare bed capacity is therefore essential for the effective management of emergency admissions, and its cost should be borne by purchasers as an essential element of an acute hospital service.

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Heron Evidence Development Ltd. was funded for this work by Mölnlycke Health Care (UK). The authors have no other conflicts of interest to declare.

Most of the literature focuses on the resources required to manage particular wound types, rather than the cost of wounds to health-care organisations. Until this information is available, wound care is unlikely to be a management priority.

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The objective of this study is to estimate the cost of wound care in a local population of approximately 590 000 using results from a wound care audit carried out in Hull and the East Riding of Yorkshire as a basis. Full results of the audit will be published separately. An audit in June 2005 provided information on patients with wounds and on their treatment. This was combined with representative National Health Service unit costs to produce an estimate of the total cost of wound care in 2005-2006. In all, 1644 patients had a total of 2300 wounds (1.44 per patient). Most (74.1%) were treated in the community by district nurses, 21.2% were treated in hospital and 4.8% were treated in residential or hospice care. More than one in four hospital inpatients (26.8%) had a wound. Median duration was 6-12 weeks. Twenty-four per cent had their wound for 6 months or more, and almost 16% of patients had remained unhealed for a year or longer. One in eight wounds (12.8%) were reported as showing signs of infection. The estimated cost of wound care in 2005-2006 was pound15 million to pound18 million ( pound2.5 million to pound3.1 million per 100 000 population). Caring for patients with wounds required the equivalent of 88.5 full-time nurses and up to 87 hospital beds. Wounds are a significant source of cost to patients as well as the health care system. The most important determinant of cost appears to be wound complications which require hospitalisation or which delay hospital discharge. Reducing costs requires a systematic focus on effective and timely diagnosis, on ensuring treatment is appropriate to the cause and condition of the wound and on active measures to prevent complications and wound-related hospitalisation. These results should be generalisable to other similar populations in the UK and elsewhere.