Angela Farr

Prioritising pain in policy making: The need for a whole systems perspective

This review aims to bring together current evidence on the impact of chronic pain in terms of its economic costs, cost to healthcare services and benefit agencies, and quality of life, and to discuss the implications of this for government policies. Quantifying the burden and cost of pain is challenging due to its multi-factorial nature and wide reaching effects. Nonetheless, there is a consensus that chronic pain has a significant impact on levels of resources across society and on quality of life. Pain is a complex bio-psychosocial experience and chronic pain is a consequence, in part, of adopting a narrow biomedical treatment approach to a problem which requires a multi-disciplinary approach to address the psychosocial, behavioural and biomedical aspects of pain. Although effective pain management interventions and programmes exist, provision of these services is inconsistent, and chronic pain is not given the priority it requires in view of the extent of its burden on individuals and society. Current relevant government policies in U.K. are discussed to highlight the need to prioritise pain and adopt a whole-systems approach to its management if governments are to successfully reduce its cost and burden.

Estimating the incidence, prevalence and true cost of asthma in the UK: secondary analysis of national stand-alone and linked databases in England, Northern Ireland, Scotland and Wales—a study protocol

Introduction Asthma is now one of the most common long-term conditions in the UK. It is therefore important to develop a comprehensive appreciation of the healthcare and societal costs in order to inform decisions on care provision and planning. We plan to build on our earlier estimates of national prevalence and costs from asthma by filling the data gaps previously identified in relation to healthcare and broadening the field of enquiry to include societal costs. This work will provide the first UK-wide estimates of the costs of asthma. In the context of asthma for the UK and its member countries (ie, England, Northern Ireland, Scotland and Wales), we seek to: (1) produce a detailed overview of estimates of incidence, prevalence and healthcare utilisation; (2) estimate health and societal costs; (3) identify any remaining information gaps and explore the feasibility of filling these and (4) provide insights into future research that has the potential to inform changes in policy leading to the provision of more cost-effective care. Methods and analysis Secondary analyses of data from national health surveys, primary care, prescribing, emergency care, hospital, mortality and administrative data sources will be undertaken to estimate prevalence, healthcare utilisation and outcomes from asthma. Data linkages and economic modelling will be undertaken in an attempt to populate data gaps and estimate costs. Separate prevalence and cost estimates will be calculated for each of the UK-member countries and these will then be aggregated to generate UK-wide estimates. Ethics and dissemination Approvals have been obtained from the NHS Scotland Information Services Divisions Privacy Advisory Committee, the Secure Anonymised Information Linkage Collaboration Review System, the NHS South-East Scotland Research Ethics Service and The University of Edinburghs Centre for Population Health Sciences Research Ethics Committee. We will produce a report for Asthma-UK, submit papers to peer-reviewed journals and construct an interactive map.

The cost effectiveness of NHS physiotherapy support for occupational health (OH) services

BackgroundMusculoskeletal pain is detrimental to quality of life (QOL) and disruptive to activities of daily living. It also places a major economic burden on healthcare systems and wider society. In 2006, the Welsh Assembly Government (WAG) established a three tiered self-referral Occupational Health Physiotherapy Pilot Project (OHPPP) comprising: 1.) telephone advice and triage, 2.) face-to-face physiotherapy assessment and treatment if required, and 3.) workplace assessment and a return-to-work facilitation package as appropriate. This study aimed to evaluate the feasibility and cost-effectiveness of the pilot service.MethodsA pragmatic cohort study was undertaken, with all OHPPP service users between September 2008 and February 2009 being invited to participate. Participants were assessed on clinical status, yellow flags, sickness absence and work performance at baseline, after treatment and at 3 month follow up. Cost-effectiveness was evaluated from both top-down and bottom-up perspectives and cost per Quality Adjusted Life Year (cost/QALY) was calculated. The cost-effectiveness analysis assessed the increase in service cost that would be necessary before the cost-effectiveness of the service was compromised.ResultsA total of 515 patients completed questionnaires at baseline. Of these, 486 were referred for face to face assessment with a physiotherapist and were included in the analysis for the current study. 264 (54.3%) and 199 (40.9%) were retained at end of treatment and 3 month follow up respectively. An improvement was observed at follow up in all the clinical outcomes assessed, as well as a reduction in healthcare resource usage and sickness absence, and improvement in self-reported work performance. Multivariate regression indicated that baseline and current physical health were associated with work-related outcomes at follow up. The costs of the service were £194-£360 per service user depending on the method used, and the health gains contributed to a cost/QALY of £1386-£7760, which would represent value for money according to current UK thresholds. Sensitivity analyses demonstrated that the service would remain cost effective until the service costs were increased to 160% per user.ConclusionsThis pragmatic evaluation of the OHPPP indicated that it was likely to be feasible in terms of service usage and could potentially be cost effective in terms of QALYs. Further, the study confirmed that improving physical health status for musculoskeletal pain patients is important in reducing problems with work capacity and related costs. This study suggests that this type of service could be potentially be useful in reducing the burden of pain and should be further investigated, ideally via randomised controlled trials assessing effectiveness and cost-effectiveness.

Challenges of harmonising data from UK national health surveys: a case study of attempts to estimate the UK prevalence of asthma.

Bright I Nwaru, Mome Mukherjee, Ramyani P Gupta, Angela Farr, Martin Heaven, Andrew Stoddart, Amrita Bandyopadhyay, Deborah Fitzsimmons, Michael Shields, Ceri Phillips, George Chamberlain, Colin Fischbacher, Christopher Dibben, Chantelle Aftab, Colin R Simpson, Ronan Lyons, David Strachan, Gwyneth A Davies, Brian McKinstry and Aziz Sheikh Asthma UK Centre for Applied Research, Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, EH8 9AG, UK Edinburgh Health Services Research Unit, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK Population Health Research Institute, St George’s, University of London, UK Swansea Centre for Health Economics (SCHE), College of Human and Health Science, Swansea University, UK CIPHER – Centre for the Improvement of Population Health through e-Records Research, Centre for Health Information, Research and Evaluation (CHIRAL), College of Medicine, Institute of Life Science 2 (ILS2), Swansea University, UK Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Health Sciences Building, Queen’s University Belfast, UK Information Services Division (ISD), NHS National Services Scotland, Edinburgh, UK School of Geography & Geosciences, Department of Geography & Sustainable Development, The University of Edinburgh, UK Asthma & Allergy Group, Institute of Life Science, College of Medicine, Swansea University, UK Corresponding author: Aziz Sheikh. Email: aziz.sheikh@ed.ac.uk

Heartlinks—A real world approach to effective Exercise Referral

Abstract Objective: To identify changes in health, coronary heart disease (CHD) risk and levels of physical activity amongst patients referred to a tailored exercise referral programme. Design: Sedentary adult patients identified as ‘at risk’ of coronary heart disease, were referred from a wide range of health professionals into a 12 month, individually tailored exercise programme closely supported by a sports scientist. A ‘before and after’ evaluation methodology was employed to measure health, CHD risk, activity levels and physiology. Results: 46 per cent of those starting Heartlinks were still in the programme after 12 months by which time they had increased their activity levels by 547 per cent, their perceived physical health scores measured using the SF36 General Health measure improved by 4.21 (p < 0.001), their mean mental scores by 3.11 (p < 0.005) and their absolute risk from Coronary Heart Disease (CHD) reduced by 8% with a relative risk reduction of 20% measured using the CALMheart risk assessment tool. Conclusion: The Heartlinks exercise referral model significantly increased physical activity levels, reduced modifiable coronary heart disease risk and improved perceptions of both physical and mental health over a 12 month period.

Evaluation of the effectiveness and cost-effectiveness of lightweight fibreglass heel casts in the management of ulcers of the heel in diabetes: a randomised controlled trial

BACKGROUND Ulcers of the foot in people with diabetes mellitus are slow to heal and result in considerable cost and patient suffering. The prognosis is worst for ulcers of the heel. OBJECTIVE To assess both the clinical effectiveness and the cost-effectiveness of lightweight fibreglass casts in the management of heel ulcers. DESIGN A pragmatic, multicentre, parallel, observer-blinded randomised controlled trial. A central randomisation centre used a computer-generated random number sequence to allocate participants to groups. SETTING Thirty-five specialist diabetic foot secondary care centres in the UK. Those recruited were aged ≥ 18 years and had diabetes mellitus complicated by ulcers of the heel of grades 2-4 on the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel scale. PARTICIPANTS In total, 509 participants [68% male, 15% with type 1 diabetes mellitus, mean age 67.5 years (standard deviation 12.4 years)] were randomised 1 : 1 to the intervention (n = 256) or the control (n = 253) arm. The primary outcome data were available for 425 participants (212 from the intervention arm and 213 from the control arm) and exceeded the total required; attrition was 16.5%. The median ulcer area at baseline was 275 mm2 [interquartile range (IQR) 104-683 mm2] in the intervention group and 206 mm2 (IQR 77-649 mm2) in the control group. There were no differences between the two groups at baseline in any parameter, neither in relation to the participant nor in relation to their ulcer. INTERVENTIONS The intervention group received usual care supplemented by the addition of an individually moulded, lightweight, fibreglass heel cast. The control group received usual care alone. The intervention phase continued either until the participants ulcer had healed (maintained for 28 days) or for 24 weeks, whichever occurred first. During this intervention phase, the participants were reviewed every 2 weeks, and the fibreglass casts were replaced when they were no longer usable. MAIN OUTCOME MEASURES The primary outcome measure was ulcer healing (confirmed by a blinded observer and maintained for 4 weeks) within 24 weeks. Other outcome measures included the time taken for the ulcer to heal, the percentage reduction in the cross-sectional area, the reduction in local pain, amputation, survival and health economic analysis. The study was powered to define a difference in healing of 15% (55% intervention vs. 40% control). RESULTS Forty-four per cent (n = 94) of the intervention group healed within 24 weeks, compared with 37% (n = 80) of the control participants (odds ratio 1.42, 95% confidence interval 0.95 to 2.14; p = 0.088), using an intention-to-treat analysis. No differences were observed between the two groups for any secondary outcome. LIMITATIONS Although the component items of care were standardised, because this was a pragmatic trial, usual care was not uniform. There was some evidence of a small excess of adverse events in the intervention group; however, non-blinded observers documented these events. There was no excess of adverse device effects. CONCLUSIONS There may be a small increase in healing with the use of a heel cast, but the estimate was not sufficiently precise to provide strong evidence of an effect. There was no evidence of any subgroup in which the intervention appeared to be particularly effective. A health economic analysis suggested that it is unlikely that the intervention represents good value for money. The provision of a lightweight heel cast may be of benefit to some individuals, but we have found no evidence to justify the routine adoption of this in clinical practice. FUTURE WORK It is unlikely that further study of this intervention will have an impact on usual clinical care, and so future efforts should be directed towards other interventions designed to improve the healing of ulcers in this population. TRIAL REGISTRATION Current Controlled Trials ISRCTN62524796. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 34. See the NIHR Journals Library website for further project information.

P218 The epidemiological, healthcare and societal burden and costs of asthma in the UK and member nations: analyses of national databases

Background Developing a comprehensive picture of the burden of asthma in the UK will enable informed national decisions about care provision and planning. We sought to provide the first UK-wide estimates of the epidemiology, healthcare utilisation and costs of asthma. Methods We undertook analyses of national health surveys, routine healthcare and administrative datasets over the period 2010–12. Economic modelling was carried out to estimate costs. Estimates were calculated for each nation and the UK as a whole. Results The UK lifetime prevalence of patient-reported symptoms suggestive of asthma in 2010–11 was 30.7% (95% Confidence Intervals [CI] 29.2–32.2; equivalent to [~] 18,949,516 people), lifetime prevalence of patient-reported physician-diagnosed asthma was 15.9% (95% CI 14.7–17.1; ~10,841,030 people), annual prevalence of patient-reported physician-diagnosed-and-treated asthma was 9.1% (95% CI 8.0–10.2; ~5,765,237 people), annual prevalence of GP reported-and-diagnosed asthma was 8.2% (95% CI 8.2–8.2; ~5,215,607 people) and annual prevalence of GP reported-and-diagnosed-and-treated asthma was 6.0% (95% CI 6.0–6.0; ~3,946,796 people). In 2011–12, asthma resulted in an estimated: 6,392,670 primary-care consultations; 93,916 inpatient-care episodes; 1,864 (317 paediatric and 1,547 adult) intensive-care unit episodes; 36,800 disability living allowance (DLA) claims; and 1,160 deaths. The estimated cost of asthma in the UK was at least £1.1billion in 2011–12: 75% of this was for primary-care (60% prescribing and 15% consultations), 13% for DLA claims, and 10% for hospital care. Conclusions We found that asthma is very common, affecting at least 3.95 million people, and that it is responsible for substantial morbidity, healthcare and societal costs in the UK. Setting ambitious targets for improving asthma outcomes is paramount and resources should be targeted to improving community-based prescribing decisions and reducing the risk of asthma exacerbations and associated hospitalisations and deaths. Funding Asthma UK, with additional support from the Edinburgh Health Services Research Unit and Farr Institute, UK.