Christopher James Sampson

Clinical characteristics of persistent frequent attenders in primary care: case–control study

BACKGROUND Most frequent attendance in primary care is temporary, but persistent frequent attendance is expensive and may be suitable for psychological intervention. To plan appropriate intervention and service delivery, there is a need for research involving standardized psychiatric interviews with assessment of physical health and health status. OBJECTIVE To compare the mental and physical health characteristics and health status of persistent frequent attenders (FAs) in primary care, currently and over the preceding 2 years, with normal attenders (NAs) matched by age, gender and general practice. METHODS Case-control study of 71 FAs (30 or more GP or practice nurse consultations in 2 years) and 71 NAs, drawn from five primary care practices, employing standardized psychiatric interview, quality of life, health anxiety and primary care electronic record review over the preceding 2 years. RESULTS Compared to NAs, FAs were more likely to report a lower quality of life (P < 0.001), be unmarried (P = 0.03) and have no educational qualifications (P = 0.009) but did not differ in employment status. FAs experienced greater health anxiety (P < 0.001), morbid obesity (P = 0.02), pain (P < 0.001) and long-term pathological and ill-defined physical conditions (P < 0.001). FAs had more depression including dysthymia, anxiety and somatoform disorders (all P < 0.001). CONCLUSIONS Persistent frequent attendance in primary care was associated with poor quality of life and high clinical complexity characterized by diverse and often persistent physical and mental multimorbidity. A brokerage model with GPs working in close liaison with skilled psychological therapists is required to manage such persistent complexity.

Occupational therapy predischarge home visits for patients with a stroke (HOVIS): results of a feasibility randomized controlled trial

Objective: To assess the feasibility of conducting a randomized controlled trial of occupational therapy predischarge home visits for people after stroke. Design: Randomized controlled trial and cohort study. We randomized eligible patients for whom there was clinical uncertainty about the need to conduct a home visit to a randomized controlled trial; patients for whom a visit was judged ‘essential’ were enrolled into a cohort study. Setting: Stroke rehabilitation unit of teaching hospital. Participants: One hundred and twenty-six participants hospitalized following recent stroke. Interventions: Predischarge home visit or structured, hospital-based interview. Main outcome measures: The primary objective was to collect information on the feasibility of a randomized controlled trial, including eligibility, control intervention and outcome assessments. The primary outcome measure was the Nottingham Extended Activities of Daily Living Scale at one month after discharge from hospital. Secondary outcomes included mood, quality of life and costs at one week and one month following discharge. Results: Ninety-three people were allocated to the randomized controlled trial; 47 were randomized to intervention and 46 to control. Thirty-three were enrolled into the cohort study. More people were allocated to the randomized controlled trial as the study progressed. One hundred and thirteen people (90%) received the proposed intervention, although there was a need for stricter protocol adherence. Follow-up was good: at one month 114 (90%) were assessed. There were no significant differences between the groups in the randomized controlled trial for the primary outcome measure at one month. The average cost of a home visit was £208. Conclusion: A trial is feasible and warranted given the resource implications of predischarge occupational therapy home visits.

Protocol Evaluating the effectiveness of a school-based group programme for parents of children at risk of ADHD: the ‘PArents, Teachers and CHildren WORKing Together (PATCHWORK)’ cluster RCT protocol

Introduction Early intervention for childhood behavioural problems may help improve health and educational outcomes in affected children and reduce the likelihood of developing additional difficulties. The National Institute for Health and Clinical Excellence guidelines for attention deficit/hyperactivity disorder (ADHD), a common childhood behavioural disorder, recommend a stepped care approach for the identification and management of these problems. Parents of children with high levels of hyperactivity and inattention may benefit from intervention programmes involving behavioural management and educational approaches. Such interventions may be further enhanced by providing training and feedback to teachers about the strategies discussed with parents. In relation to children with high levels of hyperactivity, impulsiveness and inattention, we aim to test the feasibility and effectiveness of a parenting programme (with and without an accompanying teacher session) in primary schools. Methods and analysis This clustered (at the level of school) randomised controlled trial (RCT) focuses on children in their first four school years (ages 4–8 years) in the East Midlands area of England. Parents will complete a screening measure, the Strengths and Difficulties Questionnaire, to identify children with high levels of hyperactivity/inattention. Three approaches to reducing hyperactivity and attention problems will be compared: a group programme for parents (parent-only intervention); group programme for parents combined with feedback to teachers (combined intervention); and waiting list control (no intervention). Differences between arms on the short version of Conners’ Parent and Teacher Rating Scales Revised will be compared and also used to inform the sample size required for a future definitive cluster RCT. A preliminary cost-effectiveness analysis will also be conducted. Ethics and dissemination The outcomes of this study will inform policy makers about the feasibility, acceptability and effectiveness of delivering targeted behavioural interventions within a school setting. The study has received ethical approval from the University of Nottingham Medical School Ethics Committee. Trial registration ISRCTN87634685

Cognitive behaviour therapy for long-term frequent attenders in primary care: a feasibility case series and treatment development study

BACKGROUND Most frequent attendance in primary care is temporary. Long-term frequent attendance may be suitable for psychological intervention to address health management and service use. AIM To explore the feasibility and acceptability of cognitive behaviour therapy (CBT) for long-term frequent attendance in primary care and obtain preliminary evidence regarding clinical and cost effectiveness. DESIGN AND SETTING A CBT case series was carried out in five GP practices in the East Midlands. METHOD Frequent attenders (FAs) were identified from case notes and invited by their practice for assessment, then offered CBT. Feasibility and acceptability were assessed by CBT session attendance and thematic analysis of semi-structured questionnaires. Clinical and cost effectiveness was assessed by primary care use and clinically important change on a range of health and quality of life instruments. RESULTS Of 462 FAs invited to interview, 87 (19%) consented to assessment. Thirty-two (7%) undertook CBT over a median of 3 months. Twenty-four (75%) attended at least six sessions. Eighteen FAs (86%, n = 21) reported overall satisfaction with treatment. Patients reported valuing listening without judgement alongside support to develop coping strategies. Thirteen (54%, n = 24), achieved clinically important improvement on the SF-36 Mental-Component Scale at 6-month follow-up and improved quality of life, but no improvement on other outcomes. Primary care use reduced from a median of eight contacts in 3 months at baseline (n = 32) to three contacts in 3 months at 1 year (n = 18). CONCLUSION CBT appears feasible and acceptable to a subset of long-term FAs in primary care who halved their primary care use. With improved recruitment strategies, this approach could contribute to decreasing GP workload and merits larger-scale evaluation.

Health state utility values for diabetic retinopathy: protocol for a systematic review and meta-analysis

BackgroundPeople with diabetic retinopathy tend to have lower levels of health-related quality of life than individuals with no retinopathy. Strategies for screening and treatment have been shown to be cost-effective. In order to reduce the bias in cost-effectiveness estimates, systematic reviews of health state utility values (HSUVs) are crucial for health technology assessment and the development of decision analytic models. A review and synthesis of HSUVs for the different stages of disease progression in diabetic retinopathy has not previously been conducted.Methods/DesignWe will conduct a systematic review of the available literature that reports HSUVs for people with diabetic retinopathy, in correspondence with current stage of disease progression and/or visual acuity. We will search Medline, EMBASE, Web of Science, Cost-Effectiveness Analysis Registry, Centre for Reviews and Dissemination Database, and EconLit to identify relevant English-language articles. Data will subsequently be synthesized using linear mixed effects modeling meta-regression. Additionally, reported disease severity classifications will be mapped to a four-level grading scale for diabetic retinopathy.DiscussionThe systematic review and meta-analysis will provide important evidence for future model-based economic evaluations of technologies for diabetic retinopathy. The meta-regression will enable the estimation of utility values at different disease stages for patients with particular characteristics and will also highlight where the design of the study and HSUV instrument have influenced the reported utility values. We believe this protocol to be the first of its kind to be published.Systematic review registrationPROSPERO CRD42014012891

An Introduction to Economic Evaluation in Occupational Therapy: Cost-Effectiveness of Pre-Discharge Home Visits after Stroke (HOVIS)

Introduction: Occupational therapy interventions, such as home visits, have been identified as being resource-intensive, but cost-effectiveness analyses are rarely, if ever, carried out. We sought to estimate the cost-effectiveness of occupational therapy home visits after stroke, as part of a feasibility study, and to demonstrate the value and methods of economic evaluation. Method: We completed a cost-effectiveness analysis of pre-discharge occupational therapy home visits after stroke compared with a hospital-based interview, carried out alongside a feasibility randomized controlled trial. Our primary outcome was quality-adjusted life years. Full cost and outcome data were available for 65 trial participants. Findings: We found that the mean total cost of a home visit was £183, compared with £75 for a hospital interview. Home visits are shown to be slightly more effective, resulting in a cost per quality-adjusted life year of just over £20,000. Conclusion: Our analysis is the only economic evaluation of this intervention to date. Home visits are shown to be more expensive and more effective than a hospital-based interview, but our results are subject to a high level of uncertainty and should be treated as such. Further economic evaluations in this field are encouraged.

Model Registration: A Call to Action

Evidence regarding the effectiveness of health technologies can be distorted via numerous mechanisms, including publication bias, methodological errors, over- interpretation of findings and fraud. In recent years, popular science writers have brought these issues to the fore, resulting in popular movements to improve the credibility of science. One particularly effective campaign has been that of the AllTrials movement, which focuses on the pre-registration and reporting of all clinical trials [1]. Many of the concerns that led to this campaign can be observed in the context of decision modelling. In 2010, researchers called for the creation of a collaborative organisation to oversee a registry of decision models [2]. The concept was not realised. In recent years, the landscape of academic publishing and collaboration has changed dramatically. In this editorial, we restate the call for a model registry and recommend actionable steps for its introduction.

Identifying objects of value at the end of life

End-of-life care has a number of characteristics that make economic evaluation particularly challenging. These include proximity to death, the improbability of survival gain, individuals’ changing priorities, declining cognition and effects on close persons. In view of these particularities of end-of-life care, some researchers have determined that current ‘extra-welfarist’ approaches to defining do not adequately reflect well-being. As a result, suggestions are being made that would see the QALY approach either replaced or subject to significant redefinition. The purported goal of adopting alternative evaluation approaches is to extend the evaluative space ‘beyond’. The purpose of this chapter is to guide the definition of what should be included in the evaluative space in end-of-life care.

A randomised controlled trial of laser scanning and casting for the construction of ankle–foot orthoses

Background: Three-dimensional laser scanning has been used for patient measurement for cranial helmets and spinal braces. Ankle–foot orthoses are commonly prescribed for children with orthopaedic conditions. This trial sought to compare ankle–foot orthoses produced by laser scanning or traditional plaster casting. Objectives: Assessment of the effectiveness and efficiency of using laser scanning to produce ankle–foot orthoses. Study design: Randomised controlled trial with blinding of orthotists and patients to the construction technique used. Methods: A randomised double-blind trial comparing fabrication of ankle–foot orthoses from casts or laser scans. Results: The time spent in the rectification and moulding of scanned ankle–foot orthoses was around 50% less than for cast ankle–foot orthoses. A non-significant increase of 9 days was seen in the time to delivery to the patient for laser scanning with computer-aided design and computer-aided manufacturing. There was a higher incidence of problems with the scan-based ankle–foot orthoses at delivery of the device, but no difference in how long the ankle–foot orthoses lasted. Costs associated with laser scanning were not significantly different from traditional methods of ankle–foot orthosis manufacture. Conclusion: Compared with conventional casting techniques, laser scan–based ankle–foot orthosis manufacture did not significantly improve either the quality of the final product or the time to delivery. Clinical relevance Ankle–foot orthoses (AFOs) are a common requirement for chronic neurological conditions during childhood. Improved efficiency of provision of AFOs would benefit children and families by reducing the delay in provision of devices and would benefit the health service by making best use of valuable orthotist time.

Micro-costing diabetic eye screening: estimation of personal expense, attendance and health care resource use

© 2016 Wichtig Publishing visual acuity (VA) was 53.9, 59.1, and 55.6 letters, and central retinal thickness (CRT) was 414.8, 370.4, and 430.1 μm, respectively. At 1 year, in T1, T2, and T3, the mean VA improved by 4.4, 1.9, and 4.6 letters, accompanied by a reduction in mean CRT of 57.7, 34.0, and 92.9 μm, respectively. The VA improvements in T1 were similar to T3 at 1 year but with a lower mean number of injections (T1, 3.7; T3, 4.7) and visits (T1, 6.4; T3, 8.4). In treatment-naïve patients at 1 year, VA outcomes stratified by baseline VA of <23, ≥23 to <39, ≥39 to <60, ≥60 to <74, and ≥74 letters were 11.8, 15.0, 6.2, 1.7, and -2.4 letters, with a mean of 2.3, 2.8, 3.7, 4.1, and 4.0 injections, respectively. The rate of ocular and nonocular serious adverse events reported was 0.38% and 4.86%, respectively. Conclusions: Prior Ranibizumab-treated patients showed higher VA and lower CRT at baseline versus treatment-naïve patients. VA improved over one year irrespective of previous treatment status. Ranibizumab 0.5 mg showed substantial improvements in VA in treatment-naïve patients with low baseline VA in a real-world scenario.