Anne Ludbrook

Using discrete choice modelling in priority setting: an application to clinical service developments.

Limited resources for health care means that techniques are required to aid the process of priority setting. This paper represents one of the first attempts to use discrete choice modelling (DCM) within the area of priority setting. It is shown how the technique can be used to estimate cost per unit of benefit ratios for competing clinical service developments. Integer programming is proposed as a method to be used, alongside DCM, to help policy makers select the optimal combination of clinical service developments within a given budget. The technique is also shown to be internally valid and internally consistent. It is argued that DCM is a potentially useful technique to be used within the area of priority setting more generally. However, further work is required to address methodological issues around the technique.

What works with men? A systematic review of health promoting interventions targeting men

BackgroundEncouraging men to make more effective use of (preventive) health services is considered one way of improving their health. The aim of this study was to appraise the available evidence of effective interventions aimed at improving mens health.MethodsSystematic review of relevant studies identified through 14 electronic databases and other information resources. Results were pooled within health topic and described qualitatively.ResultsOf 11,749 citations screened, 338 articles were assessed and 27 met our inclusion criteria. Most studies were male sex-specific, i.e. prostate cancer screening and testicular self-examination. Other topics included alcohol, cardiovascular disease, diet and physical activity, skin cancer and smoking cessation. Twenty-three interventions were effective or partially effective and 18 studies satisfied all quality criteria.ConclusionMost of the existing evidence relates to male sex-specific health problems as opposed to general health concerns relevant to both men and women. There is little published evidence on how to improve mens uptake of services. We cannot conclude from this review that targeting men works better than providing services for all people. Large-scale studies are required to help produce evidence that is sufficiently robust to add to the small evidence base that currently exists in this field.

Collecting unit cost data in multicentre studies

International comparisons of health care systems and services have created increased interest in the comparability of cost results. This study compared top-down and bottom-up approaches to collecting unit cost data across centres in the context of examining the cost-effectiveness of dialysis therapy across Europe. The study tested whether health care technologies in different countries can be costed using consistent and transparent methods to increase the comparability of results. There was more agreement across the approaches for peritoneal dialysis than for than haemodialysis, with differences, respectively of €91–1,687 vs. 333–7,314 per patient per year. Haemodialysis results showed greatest differences where dialysis units were integrated as part of larger hospitals. Deciding which approach to adopt depends largely on the technology. However, bottom-up costing should be considered for technologies with a large component of staff input or overheads, significant sharing of staff or facilities between technologies or patient groups and health care costing systems which do not routinely allocate costs to the intervention level. In these circumstances this costing approach could increase consistency and transparency and hence comparability of cost results.

The impact of a bodyweight and physical activity intervention (BeWEL) initiated through a national colorectal cancer screening programme: randomised controlled trial

Objective To evaluate the impact of a diet and physical activity intervention (BeWEL) on weight change in people with a body mass index >25 weight (kg)/height (m)2 at increased risk of colorectal cancer and other obesity related comorbidities. Design Multicentre, parallel group, randomised controlled trial. Setting Four Scottish National Health Service health boards. Participants 329 overweight or obese adults (aged 50 to 74 years) who had undergone colonoscopy after a positive faecal occult blood test result, as part of the national bowel screening programme, and had a diagnosis of adenoma confirmed by histopathology. 163 were randomised to intervention and 166 to control. Intervention Participants were randomised to a control group (weight loss booklet only) or 12 month intervention group (three face to face visits with a lifestyle counsellor plus monthly 15 minute telephone calls). A goal of 7% reduction in body weight was set and participants received a personalised energy prescription (2508 kJ (600 kcal) below that required for weight maintenance) and bodyweight scales. Motivational interviewing techniques explored self assessed confidence, ambivalence, and personal values concerning weight. Behavioural strategies included goal setting, identifying intentions of implementation, self monitoring of body weight, and counsellor feedback about reported diet, physical activity, and weight change. Main outcome measures The primary outcome was weight change over 12 months. Secondary outcomes included changes in waist circumference, blood pressure, fasting cardiovascular biomarkers, and glucose metabolism variables, physical activity, diet, and alcohol consumption. Results At 12 months, data on the primary outcome were available for 148 (91%) participants in the intervention group and 157 (95%) in the control group. Mean weight loss was 3.50 kg (SD 4.91) (95% confidence interval 2.70 to 4.30) in the intervention group compared with 0.78 kg (SD 3.77) (0.19 to 1.38) in the control group. The group difference was 2.69 kg (95% confidence interval 1.70 to 3.67). Differences between groups were significant for waist circumference, body mass index, blood pressure, blood glucose level, diet, and physical activity. No reported adverse events were considered to be related to trial participation. Conclusions Significant weight loss can be achieved by a diet and physical activity intervention initiated within a national colorectal cancer screening programme, offering considerable potential for risk reduction of disease in older adults. Trial registration Current Controlled Trials ISRCTN53033856.

Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial

Objective To assess the clinical effectiveness and cost effectiveness of a policy to provide breastfeeding groups for pregnant and breastfeeding women. Design Cluster randomised controlled trial with prospective mixed method embedded case studies to evaluate implementation processes. Setting Primary care in Scotland. Participants Pregnant women, breastfeeding mothers, and babies registered with 14 of 66 eligible clusters of general practices (localities) in Scotland that routinely collect breastfeeding outcome data. Intervention Localities set up new breastfeeding groups to provide population coverage; control localities did not change group activity. Main outcome measures Primary outcome: any breast feeding at 6-8 weeks from routinely collected data for two pre-trial years and two trial years. Secondary outcomes: any breast feeding at birth, 5-7 days, and 8-9 months; maternal satisfaction. Results Between 1 February 2005 and 31 January 2007, 9747 birth records existed for intervention localities and 9111 for control localities. The number of breastfeeding groups increased from 10 to 27 in intervention localities, where 1310 women attended, and remained at 10 groups in control localities. No significant differences in breastfeeding outcomes were found. Any breast feeding at 6-8 weeks declined from 27% to 26% in intervention localities and increased from 29% to 30% in control localities (P=0.08, adjusted for pre-trial rate). Any breast feeding at 6-8 weeks increased from 38% to 39% in localities not participating in the trial. Women who attended breastfeeding groups were older (P<0.001) than women initiating breast feeding who did not attend and had higher income (P=0.02) than women in the control localities who attended postnatal groups. The locality cost was £13u2009400 (€14u2009410;

Oral versus intra‐vaginal imidazole and triazole anti‐fungal agents for the treatment of uncomplicated vulvovaginal candidiasis (thrush): a systematic review

20u2009144) a year. Conclusion A policy for providing breastfeeding groups in relatively deprived areas of Scotland did not improve breastfeeding rates at 6-8 weeks. The costs of running groups would be similar to the costs of visiting women at home. Trial registration Current Controlled Trials ISRCTN44857041.

Budget allocation in the National Health Service.

Objectives To compare the relative effectiveness, cost effectiveness and safety of oral versus intra‐vaginal anti‐fungal treatments for uncomplicated vulvovaginal candidiasis (thrush) and establish patient preference for the route of anti‐fungal administration

Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design.

The objective of this article is to analyse the way in which budget allocation decisions have been made in the National Health Service (NHS) of Britain. Despite the criticisms of the pre-1948 health care system on the grounds of geographical inequity, it was not until nearly twenty-five years after the services inception that explicit allocation formulae were devised and implemented in an attempt to achieve equity, defined as equal financial resources for health care for those in equal need. The article is divided into four sections; the first analyses briefly the establishment of the NHS in 1948 and the failure of policy-makers to rectify the significant inequalities in the distribution of health care inputs between the regions. The second section is concerned with the official recognition of the policy problem of geographical inequality in resources and the first attempt to rectify it. In the third section the most recent set of resource allocation formulae for England, Scotland and Wales will be analysed and compared. The final section offers some brief conclusions.

Study protocol for BeWEL: The impact of a BodyWEight and physicaL activity intervention on adults at risk of developing colorectal adenomas

BACKGROUNDnSmoking in pregnancy and/or not breastfeeding have considerable negative health outcomes for mother and baby.nnnAIMnTo understand incentive mechanisms of action for smoking cessation in pregnancy and breastfeeding, develop a taxonomy and identify promising, acceptable and feasible interventions to inform trial design.nnnDESIGNnEvidence syntheses, primary qualitative survey, and discrete choice experiment (DCE) research using multidisciplinary, mixed methods. Two mother-and-baby groups in disadvantaged areas collaborated throughout.nnnSETTINGnUK.nnnPARTICIPANTSnThe qualitative study included 88 pregnant women/recent mothers/partners, 53 service providers, 24 experts/decision-makers and 63 conference attendees. The surveys included 1144 members of the general public and 497 health professionals. The DCE study included 320 women with a history of smoking.nnnMETHODSn(1) Evidence syntheses: incentive effectiveness (including meta-analysis and effect size estimates), delivery processes, barriers to and facilitators of smoking cessation in pregnancy and/or breastfeeding, scoping review of incentives for lifestyle behaviours; (2) qualitative research: grounded theory to understand incentive mechanisms of action and a framework approach for trial design; (3) survey: multivariable ordered logit models; (4) DCE: conditional logit regression and the log-likelihood ratio test.nnnRESULTSnOut of 1469 smoking cessation and 5408 breastfeeding multicomponent studies identified, 23 smoking cessation and 19 breastfeeding studies were included in the review. Vouchers contingent on biochemically proven smoking cessation in pregnancy were effective, with a relative risk of 2.58 (95% confidence interval 1.63 to 4.07) compared with non-contingent incentives for participation (four studies, 344 participants). Effects continued until 3 months post partum. Inconclusive effects were found for breastfeeding incentives compared with no/smaller incentives (13 studies) but provider commitment contracts for breastfeeding show promise. Intervention intensity is a possible confounder. The acceptability of seven promising incentives was mixed. Women (for vouchers) and those with a lower level of education (except for breastfeeding incentives) were more likely to disagree. Those aged ≤u200944 years and ethnic minority groups were more likely to agree. Agreement was greatest for a free breast pump and least for vouchers for breastfeeding. Universal incentives were preferred to those targeting low-income women. Initial daily text/telephone support, a quitting pal, vouchers for >u2009£20.00 per month and values up to £80.00 increase the likelihood of smoking cessation. Doctors disagreed with provider incentives. A ladder logic model emerged through data synthesis and had face validity with service users. It combined an incentive typology and behaviour change taxonomy. Autonomy and well-being matter. Personal difficulties, emotions, socialising and attitudes of others are challenges to climbing a metaphorical ladder towards smoking cessation and breastfeeding. Incentive interventions provide opportunity rungs to help, including regular skilled flexible support, a pal, setting goals, monitoring and outcome verification. Individually tailored and non-judgemental continuity of care can bolster womens capabilities to succeed. Rigid, prescriptive interventions placing the onus on women to behave healthily risk them feeling pressurised and failing. To avoid losing face, women may disengage.nnnLIMITATIONSnIncluded studies were heterogeneous and of variable quality, limiting the assessment of incentive effectiveness. No cost-effectiveness data were reported. In surveys, selection bias and confounding are possible. The validity and utility of the ladder logic model requires evaluation with more diverse samples of the target population.nnnCONCLUSIONSnIncentives provided with other tailored components show promise but reach is a concern. Formal evaluation is recommended. Collaborative service-user involvement is important.nnnSTUDY REGISTRATIONnThis study is registered as PROSPERO CRD42012001980.nnnFUNDINGnThe National Institute for Health Research Health Technology Assessment programme.

Services just for men? Insights from a national study of the well men services pilots

BackgroundColorectal cancer (CRC) is the third most commonly diagnosed cancer and the second highest cause of cancer death in the UK. Most cases occur in people over 50 years and CRC often co-exists with other lifestyle related disorders including obesity, type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). These diseases share risk factors related to the metabolic syndrome including large body size, abnormal lipids and markers of insulin resistance indicating common aetiological pathways.Methods/DesignThis 3 year study will be a two-arm, multicentre, randomised controlled trial comparing the BeWEL lifestyle (diet, physical activity and behaviour change) programme against usual care. The pre-trial development will take 6 months and participants will be recruited over a 12 month period and undertake the intervention and follow up for 12 months (total 24 months recruitment and intervention implementation) with a further 6 months for data collection, analysis and interpretation.Four hundred and fifty two participants who have had a colorectal adenoma detected and removed (through the national colorectal screening programme) will provide 80% power to detect a weight loss of 7% over 12 months.Primary outcomes are changes in body weight and waist circumference. Secondary outcomes will include cardiovascular risk factors, psycho-social measures and intervention costs.DiscussionThe results from this study will enhance the evidence base for lifestyle change in patients at higher risk of chronic disease including obesity related cancers.International Standard Randomised Controlled Trials No: ISRCTN53033856