Pippa Anderson

Prioritisation of specialist health care services: going beyond the evidence

Materials and methods A Prioritisation Panel representing a wide range of stakeholders was convened. A master list of services was achieved through matching against criteria (including high cost individual care, growth or implementation that exceeded an incremental cost of £50,000, uncertainty about evidence or ability to benefit) for evidence and prioritisation. Condition-Treatment pairs were created for the services falling under the remit of WHSSC, evidence reviews undertaken and evidence of effectiveness and cost effectiveness were collated to inform the decision making process. Discreet choice methods were used to rank order and apply a cut off point for commissioning or not. Score cards were developed to score for scientific rigour, inclusiveness, transparency, independence, challenge, review, support for implementation and timeliness. These features relate to the procedural justice requirement for ‘accountability for reasonableness’ described in the published literature. Results The common finding for the condition treatment pairs was lack of evidence to guide confident decision making. Through the process, the Panel was required to make judgements: scientific value judgements about interpreting the quality and significance of the evidence available and social value judgements. These latter were guided by four principles: respect for autonomy, non-maleficence, beneficence and distributive justice. A prioritisation and commissioning list was created and specific services identified for commissioning and decommissioning.

Survey of digestive health across Europe: Final report. Part 2: The economic impact and burden of digestive disorders

Digestive diseases – gastrointestinal and liver disorders – are common across Europe, causing more than 500 000 deaths in 2008 in the 28 EU member states (and more than 900 000 deaths in the whole of Europe, including Russia and other non-EU states). However, United European Gastroenterology (UEG) believe that these diseases are poorly understood, have usually attracted relatively little attention from a policy perspective and do not attract significant research funding, in comparison with many other disciplines. One of the remits of the UEG is to raise the political and public awareness of gastrointestinal disorders throughout Europe. To facilitate this, accurate and up to date information is required on the human and health consequences and on the economic burden of digestive disorders.

Costs and outcomes associated with IVF using recombinant FSH

Cost and outcome estimates based on clinical trial data may not reflect usual clinical practice, yet they are often used to inform service provision and budget decisions. To expand understanding of assisted reproduction treatment in clinical practice, an economic evaluation of IVF/intracytoplasmic sperm injection (ICSI) data from a single assisted conception unit (ACU) in England was performed. A total of 1418 IVF/ICSI cycles undertaken there between October 2001 and January 2006 in 1001 women were analysed. The overall live birth rate was 22% (95% CI: 19.7-24.2), with the 30- to 34-year age group achieving the highest rate (28%). The average recombinant FSH (rFSH) dose/cycle prescribed was 1855 IU. Average cost of rFSH/cycle was 646 pound(SD: 219 pound), and average total cost/cycle was 2932 pound (SD: 422 pound). Economic data based on clinical trials informing current UK guidance assumes higher doses of rFSH dose/cycle (1750-2625 IU), higher average cost of drugs/cycle (1179 pound), and higher average total cost/cycle (3266 pound). While the outcomes in this study matched UK averages, total cost/cycle was lower than those cited in UK guidelines. Utilizing the protocols and (lower) rFSH dosages reported in this study may enable other ACU to provide a greater number of IVF/ICSI cycles to patients within given budgets.

Home-based pre-surgical psychological intervention for knee osteoarthritis (HAPPiKNEES): a feasibility randomized controlled trial

Objective: To determine the feasibility of conducting a trial of a pre-surgical psychological intervention on pain, function, and mood in people with knee osteoarthritis listed for total knee arthroplasty. Design: Multi-centre, mixed-methods feasibility randomized controlled trial of intervention plus usual care versus usual care. Setting: Participants’ homes or hospital. Participants: Patients with knee osteoarthritis listed for total knee arthroplasty and score >7 on either subscales of Hospital Anxiety and Depression Scale. Intervention: Up-to 10 sessions of psychological intervention (based on cognitive behavioural therapy). Main measures: Feasibility outcomes (recruitment and retention rates, acceptability of trial procedures and intervention, completion of outcome measures), and standardized questionnaires assessing pain, function, and mood at baseline, and four and six months post-randomisation. Results: Of 222 people screened, 81 did not meet inclusion criteria, 64 did not wish to participate, 26 were excluded for other reasons, and 51 were randomized. A total of 30 completed 4-month outcomes and 25 completed 6-month outcomes. Modal number of intervention sessions completed was three (range 2–8). At 6-month follow-up, mood, pain, and physical function scores were consistent with clinically important benefits from intervention, with effect sizes ranging from small (d = 0.005) to moderate (d = 0.74), and significant differences in physical function between intervention and usual care groups (d = 1.16). Feedback interviews suggested that participants understood the rationale for the study, found the information provided adequate, the measures comprehensive, and the intervention acceptable. Conclusion: A definitive trial is feasible, with a total sample size of 444 people. Pain is a suitable primary outcome, but best assessed 6 and 12 months post-surgery.

Projecting pharmaceutical expenditure in EU5 to 2021: adjusting for the impact of discounts and rebates

BackgroundWithin (European) healthcare systems, the predominant goal for pharmaceutical expenditure is cost containment. This is due to a general belief among healthcare policy makers that pharmaceutical expenditure—driven by high prices—will be unsustainable unless further reforms are enacted.ObjectiveThe aim of this paper is to provide more realistic expectations of pharmaceutical expenditure for all key stakeholder groups by estimating pharmaceutical expenditure at ‘net’ prices. We also aim to estimate any gaps developing between list and net pharmaceutical expenditure for the EU5 countries (i.e. France, Germany, Italy, Spain, and the UK).MethodsWe adjusted an established forecast of pharmaceutical expenditure for the EU5 countries, from 2017 to 2021, by reflecting discounts and rebates not previously considered, i.e. we moved from ‘list’ to ‘net’ prices, as far as data were available.ResultsWe found an increasing divergence between expenditure measured at list and net prices. When the forecasts for the five countries were aggregated, the EU5 (unweighted) average historical growth (2010–2016) rate fell from 3.4% compound annual growth rate at list to 2.5% at net. For the forecast, the net growth rate was estimated at 1.5 versus 2.9% at list.ConclusionsOur results suggest that future growth in pharmaceutical expenditure in Europe is likely to be (1) lower than previously understood from forecasts based on list prices and (2) below predicted healthcare expenditure growth in Europe and in line with long-term economic growth rates. For policy makers concerned about the sustainability of pharmaceutical expenditure, this study may provide some comfort, in that the perceived problem is not as large as expected.

Short-term health and social impacts of energy-efficiency investments in low-income communities: a controlled field study

Abstract Background During 2012–15, £45 million was invested to improve the energy-efficiency of 4800 houses in low-income areas across Wales. Houses received measures such as external wall insulation, new windows and doors, upgrades to the heating system, and connection to the gas network. This study aimed to establish the short-term health and social impacts of these investments. Methods A quasi-experimental field study with a controlled, before and after design was conducted (364 individuals in improved houses [intervention], 418 in houses with no improvements [control]). Any adult living in 24 selected intervention areas and matched control areas (n=23) was eligible for inclusion. Self-completed questionnaires, administered via a drop-off-and-collect method, were collected in the winter months (December to February) before and after installation of the energy efficiency measures. Health outcomes were mental health composite scale (MCS) and physical health composite scale (PCS) scores of the SF-12v2, SF-6D utility scores derived from the SF-12v2, self-reported respiratory symptoms, and subjective wellbeing. Social outcomes were financial difficulties and stress, food security, thermal comfort, housing conditions, and social isolation. The study used measures validated in previous research. Linear, ordered multinomial, and logistic multilevel models were constructed with measurement occasions nested within individuals. Findings After controlling for sex, age, housing benefit, household income, and smoking status, we found that investments were not associated with improvements in MCS (B=0·00, 95% CI −1·60 to 1·60) or PCS (0·98, −0·34 to 2·28) scores, SF-6D utilities (−0·01, −0·04 to 0·02), or self-reported respiratory symptoms (−0·14, −0·54 to 0·26). However, people who received energy-efficiency measures reported improved subjective wellbeing compared with controls (B=0·38, 95% CI 0·12 to 0·65), and fewer financial difficulties (−0·15, −0·25 to −0·05); they reported higher thermal comfort (odds ratio 3·83, 95% CI 2·40 to 5·90), higher satisfaction with the improvement of their homes (3·87, 2·51 to 5·96), and less reluctance to invite friends or family to their homes (0·32, 0·13 to 0·77). Interpretation Although there is no evidence that energy-efficiency investments provide physical health benefits in the short term, they improve social and economic conditions that are conducive to better health. Longer term studies are needed to establish the health impacts of energy-efficiency investments. Funding National Institute for Health Research (NIHR) Public Health Research (PHR) programme (project number 11/3020/05).

Use of dermal regeneration templates in a low resource environment

Modern burn care in a sophisticated well-resourced centre in a rich country utilises an increasing number of expensive adjuncts to optimise outcomes such as dermal templates, cultured keratinocytes, biological and silver impregnated dressings. Translating the use of these into a low resource environment is not a simple matter of providing the materials free of charge and there needs to be careful consideration of both the positive and negative consequences and the impact on both an individual and a population level.

Hormone replacement therapy use in UK general practice: Duration, discontinuation and women’s experience

Objective Investigate characteristics of women treated with combined estrogen and progestogen hormone replacement therapy (study-HRT); HRT patterns; reasons and outcomes associated with HRT discontinuation. Study design Retrospective observational study using The Health Improvement Network database examining women’s characteristics and treatment patterns (Database). Postal questionnaire exploring reasons and outcomes associated with HRT discontinuation (Survey). Main outcome measures Database: Demographic and clinical characteristics. HRT patterns, time from diagnosis to treatment, duration of treatment, type of treatment and change of treatment (switch, add-on, re-start and discontinuation). Survey: HRT therapy status, menopause rating scale and reasons for discontinuation. Results Database: 8968 women prescribed study-HRT between January 2006 and January 2010 were matched 1:1 on GP practice and age with women not prescribed HRT. Women prescribed study-HRT were more likely to be a current/past smoker (p<0.05) and experienced higher levels of co-morbidities related to menopause (p < 0.05) versus women not prescribed HRT. Treatment duration was approximately 14 months and 95% changed treatment during the study. Survey: 116 respondents. Women on HRT had lower MRS scores (p < 0.05) than women who discontinued HRT. Main reasons for discontinuation were medical advice, side-effects/potential side-effects. Fear of breast cancer was also stated as a reason. Conclusions Duration of HRT was relatively short, with 95% of women changing treatment. HRT discontinuation was associated with more severe menopause symptoms. Medical advice and concerns about side-effects were major reasons for the discontinuation, suggesting that there was a need for a balanced dialogue with women about risks and benefits of HRT, as emphasised by NICE guidance.

Investigating the feasibility of an enhanced contact intervention in self-harm and suicidal behaviour: a protocol for a randomised controlled trial delivering a Social support and Wellbeing Intervention following Self Harm (SWISH)

Introduction Self-harm is a strong predictor for suicide. Risks for repeat behaviour are heightened in the aftermath of an index episode. There is no consensus on the most effective type of intervention to reduce repetition. Treatment options for patients who do not require secondary mental health services include no support, discharge to general practitioner or referral to primary care mental health support services. The aim of this study is to assess whether it is feasible to deliver a brief intervention after an episode and whether this can reduce depressive symptoms and increase the sense of well-being for patients who self-harm. Methods This is a non-blinded parallel group randomised clinical trial. 120 patients presenting with self-harm and/or suicidal ideation to mental health services over a 12-month period who are not referred to secondary services will be randomised to either intervention plus treatment as usual (TAU), or control (TAU only). Patients are assessed at baseline, 4 and 12 weeks with standardised measures to collect data on depression, well-being and service use. Primary outcome is depression scores and secondary outcomes are well-being scores and use of services. The findings will indicate whether a rapid response brief intervention is feasible and can reduce depression and increase well-being among patients who self-harm and do not require secondary services. Ethics and dissemination Ethical approval was granted by the UK National Health Service (NHS) Ethics Committee process (REC 6: 14/WA/0074). The findings of the trial will be disseminated through presentations to the participating Health Board and partners, peer-reviewed journals and national and international conferences. Trial registration number ISRCTN76914248; Pre-results.