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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
The role of digital communication in patient–clinician communication for NHS providers of specialist clinical services for young people [the Long-term conditions Young people Networked Communication (LYNC) study]: a mixed-methods study
<jats:sec id="abs1-1"><jats:title>Background</jats:title><jats:p>Young people (aged 16–24 years) with long-term health conditions tend to disengage from health services, resulting in poor health outcomes. They are prolific users of digital communications. Innovative UK NHS clinicians use digital communication with these young people. The NHS plans to use digital communication with patients more widely.</jats:p></jats:sec><jats:sec id="abs1-2"><jats:title>Objectives</jats:title><jats:p>To explore how health-care engagement can be improved using digital clinical communication (DCC); understand effects, impacts, costs and necessary safeguards; and provide critical analysis of its use, monitoring and evaluation.</jats:p></jats:sec><jats:sec id="abs1-3"><jats:title>Design</jats:title><jats:p>Observational mixed-methods case studies; systematic scoping literature reviews; assessment of patient-reported outcome measures (PROMs); public and patient involvement; and consensus development through focus groups.</jats:p></jats:sec><jats:sec id="abs1-4"><jats:title>Setting</jats:title><jats:p>Twenty NHS specialist clinical teams from across England and Wales, providing care for 13 different long-term physical or mental health conditions.</jats:p></jats:sec><jats:sec id="abs1-5"><jats:title>Participants</jats:title><jats:p>One hundred and sixty-five young people aged 16–24 years living with a long-term health condition; 13 parents; 173 clinical team members; and 16 information governance specialists.</jats:p></jats:sec><jats:sec id="abs1-6"><jats:title>Interventions</jats:title><jats:p>Clinical teams and young people variously used mobile phone calls, text messages, e-mail and voice over internet protocol.</jats:p></jats:sec><jats:sec id="abs1-7"><jats:title>Main outcome measures</jats:title><jats:p>Empirical work – thematic and ethical analysis of qualitative data; annual direct costs; did not attend, accident and emergency attendance and hospital admission rates plus clinic-specific clinical outcomes. Scoping reviews–patient, health professional and service delivery outcomes and technical problems. PROMs: scale validity, relevance and credibility.</jats:p></jats:sec><jats:sec id="abs1-8"><jats:title>Data sources</jats:title><jats:p>Observation, interview, structured survey, routinely collected data, focus groups and peer-reviewed publications.</jats:p></jats:sec><jats:sec id="abs1-9"><jats:title>Results</jats:title><jats:p>Digital communication enables access for young people to the right clinician when it makes a difference for managing their health condition. This is valued as additional to traditional clinic appointments. This access challenges the nature and boundaries of therapeutic relationships, but can improve them, increase patient empowerment and enhance activation. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information and communication failures, but clinicians and young people mitigate these risks. Workload increases and the main cost is staff time. Clinical teams had not evaluated the impact of their intervention and analysis of routinely collected data did not identify any impact. There are no currently used generic outcome measures, but the Patient Activation Measure and the Physicians’ Humanistic Behaviours Questionnaire are promising. Scoping reviews suggest DCC is acceptable to young people, but with no clear evidence of benefit except for mental health.</jats:p></jats:sec><jats:sec id="abs1-10"><jats:title>Limitations</jats:title><jats:p>Qualitative data were mostly from clinician enthusiasts. No interviews were achieved with young people who do not attend clinics. Clinicians struggled to estimate workload. Only eight full sets of routine data were available.</jats:p></jats:sec><jats:sec id="abs1-11"><jats:title>Conclusions</jats:title><jats:p>Timely DCC is perceived as making a difference to health care and health outcomes for young people with long-term conditions, but this is not supported by evidence that measures health outcomes. Such communication is challenging and costly to provide, but valued by young people.</jats:p></jats:sec><jats:sec id="abs1-12"><jats:title>Future work</jats:title><jats:p>Future development should distinguish digital communication replacing traditional clinic appointments and additional timely communication. Evaluation is needed that uses relevant generic outcomes.</jats:p></jats:sec><jats:sec id="abs1-13"><jats:title>Study registration</jats:title><jats:p>Two of the reviews in this study are registered as PROSPERO CRD42016035467 and CRD42016038792.</jats:p></jats:sec><jats:sec id="abs1-14"><jats:title>Funding</jats:title><jats:p>The National Institute for Health Research Health Services and Delivery Research programme.</jats:p></jats:sec>
Benefits and Costs of Digital Consulting in Clinics Serving Young People With Long-Term Conditions: Mixed-Methods Approach.
BACKGROUND: Since the introduction of digital health technologies in National Health Service (NHS), health professionals are starting to use email, text, and other digital methods to consult with their patients in a timely manner. There is lack of evidence regarding the economic impact of digital consulting in the United Kingdom (UK) NHS. OBJECTIVE: This study aimed to estimate the direct costs associated with digital consulting as an adjunct to routine care at 18 clinics serving young people aged 16-24 years with long-term conditions. METHODS: This study uses both quantitative and qualitative approaches. Semistructured interviews were conducted with 173 clinical team members on the impacts of digital consulting. A structured questionnaire was developed and used for 115 health professionals across 12 health conditions at 18 sites in the United Kingdom to collect data on time and other resources used for digital consulting. A follow-up semistructured interview was conducted with a single senior clinician at each site to clarify the mechanisms through which digital consulting use might lead to outcomes relevant to economic evaluation. We used the two-part model to see the association between the time spent on digital consulting and the job role of staff, type of clinic, and the average length of the working hours using digital consulting. RESULTS: When estimated using the two-part model, consultants spent less time on digital consulting compared with nurses (95.48 minutes; P<.001), physiotherapists (55.3 minutes; P<.001), and psychologists (31.67 minutes; P<.001). Part-time staff spent less time using digital consulting than full-time staff despite insignificant result (P=.15). Time spent on digital consulting differed across sites, and no clear pattern in using digital consulting was found. Health professionals qualitatively identified the following 4 potential economic impacts for the NHS: decreasing adverse events, improving patient well-being, decreasing wait lists, and staff workload. We did not find evidence to suggest that the clinical condition was associated with digital consulting use. CONCLUSIONS: Nurses and physiotherapists were the greatest users of digital consulting. Teams appear to use an efficient triage system with the most expensive members digitally consulting less than lower-paid team members. Staff report showed concerns regarding time spent digitally consulting, which implies that direct costs increase. There remain considerable gaps in evidence related to cost-effectiveness of digital consulting, but this study has highlighted important cost-related outcomes for assessment in future cost-effectiveness trials of digital consulting.
Timely digital patient-clinician communication in specialist clinical services for young people: A mixed-methods study (the LYNC study)
© Frances Griffiths, Carol Bryce, Jonathan Cave, Melina Dritsaki, Joseph Fraser, Kathryn Hamilton, Caroline Huxley, Agnieszka Ignatowicz, Sung Wook Kim, Peter K Kimani, Jason Madan, Anne-Marie Slowther, Mark Sujan, Jackie Sturt. Background: Young people (aged 16-24 years) with long-term health conditions can disengage from health services, resulting in poor health outcomes, but clinicians in the UK National Health Service (NHS) are using digital communication to try to improve engagement. Evidence of effectiveness of this digital communication is equivocal. There are gaps in evidence as to how it might work, its cost, and ethical and safety issues. Objective: Our objective was to understand how the use of digital communication between young people with long-term conditions and their NHS specialist clinicians changes engagement of the young people with their health care; and to identify costs and necessary safeguards. Methods: We conducted mixed-methods case studies of 20 NHS specialist clinical teams from across England and Wales and their practice providing care for 13 different long-term physical or mental health conditions. We observed 79 clinical team members and interviewed 165 young people aged 16-24 years with a long-term health condition recruited via case study clinical teams, 173 clinical team members, and 16 information governance specialists from study NHS Trusts. We conducted a thematic analysis of how digital communication works, and analyzed ethics, safety and governance, and annual direct costs. Results: Young people and their clinical teams variously used mobile phone calls, text messages, email, and voice over Internet protocol. Length of clinician use of digital communication varied from 1 to 13 years in 17 case studies, and was being considered in 3. Digital communication enables timely access for young people to the right clinician at the time when it can make a difference to how they manage their health condition. This is valued as an addition to traditional clinic appointments and can engage those otherwise disengaged, particularly at times of change for young people. It can enhance patient autonomy, empowerment and activation. It challenges the nature and boundaries of therapeutic relationships but can improve trust. The clinical teams studied had not themselves formally evaluated the impact of their intervention. Staff time is the main cost driver, but offsetting savings are likely elsewhere in the health service. Risks include increased dependence on clinicians, inadvertent disclosure of confidentia information, and communication failures, which are mostly mitigated by young people and clinicians using common-sense approaches. Conclusions: As NHS policy prompts more widespread use of digital communication to improve the health care experience, our findings suggest that benefit is most likely, and harms are mitigated, when digital communication is used with patients who already have a relationship of trust with the clinical team, and where there is identifiable need for patients to have flexible access, such as when transitioning between services, treatments, or lived context. Clinical teams need a proactive approach to ethics, governance, and patient safety.
A randomized controlled trial and economic evaluation of the Parents Under Pressure program for parents in substance abuse treatment
© 2018 Background: There is growing interest in the provision of parenting support to substance misusing parents. Methods: This pragmatic, multi-center randomized controlled trial compared an intensive one-to-one parenting program (Parents under Pressure, PuP) with Treatment as Usual (TAU) in the UK. Parents were engaged in community-based substance misuse services and were primary caregivers of children less than 2.5 years of age. The primary outcome was child abuse potential, and secondary outcomes included measures of parental emotional regulation assessed at baseline, 6 and 12-months. A prospective economic evaluation was also conducted. Results: Of 127 eligible parents, 115 met the inclusion criteria, and subsequently parents were randomly assigned to receive PuP (n = 48) or TAU (n = 52). Child abuse potential was significantly improved in those receiving the PuP program while those in TAU showed a deterioration across time in both intent-to-treat (p < 0.03) and per-protocol analyses (p < 0.01). There was also significant reliable change (recovery/improvement) in 30.6% of the PuP group compared with 10.3% of the TAU group (p < 0.02), and deterioration in 3% compared with 18% (p < 0.02). The probability that the program is cost-effective was approximately 51.8% if decision-makers are willing to pay £1000 for a unit improvement in the primary outcome, increasing to 98.0% at a £20,000 cost-effectiveness threshold for this measure. Conclusions: Up to one-third of substance dependent parents of children under 3-years of age can be supported to improve their parenting, using a modular, one-to-one parenting program. Further research is needed.
Consensus on DEfinition of Food Allergy SEverity (DEFASE): Protocol for a systematic review.
Background and aims: The term "Food Allergy" refers to a complex global health problem with a wide spectrum of severity. However, a uniform definition of severe food allergy is currently missing. This systematic review is the preliminary step towards a state-of-the-art synopsis of the current evidence relating to the severity of IgE-mediated food allergy; it will inform attempts to develop a consensus to define food allergy severity by clinicians and other stakeholders. Methods: We will undertake a systematic review, which will involve searching international biomedical databases for published studies. Studies will be independently screened against pre-defined eligibility criteria and critically appraised by established instruments. Data will be descriptively and, if possible and applicable, quantitatively synthesised. Ethics and dissemination: This study does not require any specific ethical approval since it is a systematic review. We plan to report results from this systematic review in a peer reviewed journal. These results will be used to inform the development of an international consensus to define severe food allergy. Author's potential conflicts of interest are clearly stated. PROSPERO registration number: CRD42020183103.
Can levosimendan reduce ECMO weaning failure in cardiogenic shock?: A cohort study with propensity score analysis
© 2020 The Author(s). Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used over the last decade in patients with refractory cardiogenic shock. ECMO weaning can, however, be challenging and lead to circulatory failure and death. Recent data suggest a potential benefit of levosimendan for ECMO weaning. We sought to further investigate whether the use of levosimendan could decrease the rate of ECMO weaning failure in adult patients with refractory cardiogenic shock. Methods: We performed an observational single-center cohort study. All patients undergoing VA-ECMO from January 2012 to December 2018 were eligible and divided into two groups: group levosimendan and group control (without levosimendan). The primary endpoint was VA-ECMO weaning failure defined as death during VA-ECMO treatment or within 24 h after VA-ECMO removal. Secondary outcomes were mortality at day 28 and at 6 months. The two groups were compared after propensity score matching. P < 0.05 was considered statistically significant. Results: Two hundred patients were analyzed (levosimendan group: n = 53 and control group: n = 147). No significant difference was found between groups on baseline characteristics except for ECMO duration, which was longer in the levosimendan group (10.6 ± 4.8 vs. 6.5 ± 4.7 days, p < 0.001). Levosimendan administration started 6.6 ± 5.4 days on average following ECMO implantation. After matching of 48 levosimendan patients to 78 control patients, the duration of ECMO was similar in both groups. The rate of weaning failure was 29.1% and 35.4% in levosimendan and control groups, respectively (OR: 0.69, 95%CI: 0.25-1.88). No significant difference was found between groups for all secondary outcomes. Conclusion: Levosimendan did not improve the rate of successful VA-ECMO weaning in patients with refractory cardiogenic shock. Trial registration: ClinicalTrials.gov, NCT04323709.
Erratum: Correction to: Can levosimendan reduce ECMO weaning failure in cardiogenic shock?: a cohort study with propensity score analysis (Critical care (London, England) (2020) 24 1 (442))
An amendment to this paper has been published and can be accessed via the original article.
Cost-effectiveness of adrenaline for out-of-hospital cardiac arrest
© 2020 The Author(s). Background: The 'Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration In Cardiac Arrest' (PARAMEDIC2) trial showed that adrenaline improves overall survival, but not neurological outcomes. We sought to determine the within-trial and lifetime health and social care costs and benefits associated with adrenaline, including secondary benefits from organ donation. Methods: We estimated the costs, benefits (quality-adjusted life years (QALYs)) and incremental cost-effectiveness ratios (ICERs) associated with adrenaline during the 6-month trial follow-up. Model-based analyses explored how results altered when the time horizon was extended beyond 6 months and the scope extended to include recipients of donated organs. Results: The within-trial (6 months) and lifetime horizon economic evaluations focussed on the trial population produced ICERs of £1,693,003 (1,946,953) and £81,070 (93,231) per QALY gained in 2017 prices, respectively, reflecting significantly higher mean costs and only marginally higher mean QALYs in the adrenaline group. The probability that adrenaline is cost-effective was less than 1% across a range of cost-effectiveness thresholds. Combined direct economic effects over the lifetimes of survivors and indirect economic effects in organ recipients produced an ICER of £16,086 (18,499) per QALY gained for adrenaline with the probability that adrenaline is cost-effective increasing to 90% at a £30,000 (34,500) per QALY cost-effectiveness threshold. Conclusions: Adrenaline was not cost-effective when only directly related costs and consequences are considered. However, incorporating the indirect economic effects associated with transplanted organs substantially alters cost-effectiveness, suggesting decision-makers should consider the complexity of direct and indirect economic impacts of adrenaline. Trial registration: ISRCTN73485024. Registered on 13 March 2014.
The impact of safety net programs on early-life developmental outcomes
Existing scholarly evidence suggests that early-life environments play a critical role in shaping an individual’s long-term socioeconomic outcomes. The impact of safety net programs on early-life environments and outcomes is largely unknown. This study uses novel data to estimate the impact of the Women, Infants and Children (WIC), the Supplemental Nutrition Assistance Program (SNAP) and home visitation (HV) programs on cognitive and language outcomes in children up to 24 months. Repeated measurements on participation in public programs and early-life outcomes for a large sample of children and mothers in Memphis, Shelby county, TN were collected. Within this dataset the exposureoutcome relationship is directly observable over time. The specific structure of the data enables us to address endogeneity concerns via the use of first-difference estimators combined with a rich set of time-varying covariates. We provide empirical evidence to conclude that WIC participation is associated with a positive and statistically significant impact of 0.32 and 0.16 standard deviations in receptive communication and expressive communication scores. Overall, participation in these safety net programs is shown to have meaningfully contributed to improving developmental outcomes among children up to two years of age. Presented empirical evidence might be critical at a time when funding for WIC, SNAP or other safety-net programs is in peril.
Systematic review of economic evaluations of children's social care interventions
© 2020 Elsevier Ltd Background: Children's social care/child welfare services, are under pressure to maximize the value of resource expenditure in meeting the needs of children and young people exposed to risk factors for care entry or residing in care. Economic evaluations can support the decision to adopt, routinize or discontinue an intervention, informing the allocation of limited resources. There is a paucity of economic evaluations in children's social care, partly because this is an emerging area, hence topic-specific methods are lacking. Prior to the development and recommendation of methods, it is important to systematically synthesize those adopted to highlight challenges that have arisen and guide future research. Objective: To assess the methods applied and the cost-effectiveness evidence generated by economic evaluations of children's social care interventions. Methods: Searches of electronic databases and websites were carried out to identify full economic evaluations of children's social care interventions in journal articles and the grey literature. A narrative synthesis of methods adopted and cost-effectiveness results is presented. Results: Twenty studies were eligible for inclusion. These covered parenting programs (n = 8), in addition to a diverse range of other interventions. Cost-effectiveness analysis was the most common approach taken (n = 17) and a large number of studies concluded that the intervention was cost-effective (n = 14). Conclusion: The number of published economic evaluations of children's social care interventions is limited. The available evidence supports the adoption of several of the interventions evaluated, however, the review highlighted a number of challenges in the use of standard economic evaluations methods in this area.
Network meta-analysis to evaluate the effectiveness of interventions to increase the uptake of smoke alarms
This study is the first known to use network meta-analysis to simultaneously evaluate the effectiveness of interventions to increase the prevalence of functioning smoke alarms in households with children. The authors identified 24 primary studies from a systematic review of reviews and of more recently published primary studies, of which 23 (17 randomized controlled trials and 6 nonrandomized comparative studies) were included in 1 of the following 2 network meta-analyses: 1) possession of a functioning alarm: interventions that were more "intensive" (i.e., included components providing equipment (with or without fitting), home inspection, or both, in addition to education) generally were more effective. The intervention containing all of the aforementioned components was identified as being the most likely to be the most effective (probability (best) = 0.66), with an odds ratio versus usual care of 7.15 (95% credible interval: 2.40, 22.73); 2) type of battery-powered alarms: ionization alarms with lithium batteries were most likely to be the best type for increasing functioning possession (probability (best) = 0.69). Smoke alarm promotion programs should ensure they provide the combination of interventions most likely to be effective. © The Author 2011. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved.
Economic outcomes associated with deep surgical site infection in patients with an open fracture of the lower limb
©2018 The British Editorial Society of Bone & Joint Surgery Aims: The aim of this study was to estimate economic outcomes associated with deep surgical site infection (SSI) in patients with an open fracture of the lower limb. Patients and Methods: A total of 460 patients were recruited from 24 specialist trauma hospitals in the United Kingdom Major Trauma Network. Preference-based health-related quality-of-life outcomes, assessed using the EuroQol EQ-5D-3L and the 6-Item Short-Form Health Survey questionnaire (SF-6D), and economic costs (£, 2014/2015 prices) were measured using participant-completed questionnaires over the 12 months following injury. Descriptive statistics and multivariate regression analysis were used to explore the relationship between deep SSI and health utility scores, quality-adjusted life-years (QALYs), and health and personal social service (PSS) costs. Results: Deep SSI was associated with lower EQ-5D-3L derived QALYs (adjusted mean difference -0.102, 95% confidence interval (CI) -0.202 to 0.001, p = 0.047) and increased health and social care costs (adjusted mean difference £1950; 95% CI £1383 to £5285, p = 0.250) versus patients without deep SSI over the 12 months following injury. Conclusion: Deep SSI may lead to significantly impaired health-related quality of life and increased economic costs. Our economic estimates can be used to inform clinical and budgetary service planning and can act as reference data for future economic evaluations of preventive or treatment interventions.
A methodological framework for assessing agreement between cost-effectiveness outcomes estimated using alternative sources of data on treatment costs and effects for trial-based economic evaluations
© 2017, The Author(s). A new methodological framework for assessing agreement between cost-effectiveness endpoints generated using alternative sources of data on treatment costs and effects for trial-based economic evaluations is proposed. The framework can be used to validate cost-effectiveness endpoints generated from routine data sources when comparable data is available directly from trial case report forms or from another source. We illustrate application of the framework using data from a recent trial-based economic evaluation of the probiotic Bifidobacterium breve strain BBG administered to babies less than 31 weeks of gestation. Cost-effectiveness endpoints are compared using two sources of information; trial case report forms and data extracted from the National Neonatal Research Database (NNRD), a clinical database created through collaborative efforts of UK neonatal services. Focusing on mean incremental net benefits at £30,000 per episode of sepsis averted, the study revealed no evidence of discrepancy between the data sources (two-sided p values >0.4), low probability estimates of miscoverage (ranging from 0.039 to 0.060) and concordance correlation coefficients greater than 0.86. We conclude that the NNRD could potentially serve as a reliable source of data for future trial-based economic evaluations of neonatal interventions. We also discuss the potential implications of increasing opportunity to utilize routinely available data for the conduct of trial-based economic evaluations.