Sophie Coronini-Cronberg

The Impact of a Free Older Persons’ Bus Pass on Active Travel and Regular Walking in England

OBJECTIVES We assessed the potential public health benefit of the National Bus Pass, introduced in 2006, which permits free local bus travel for older adults (≥ 60 years) in England. METHODS We performed regression analyses with annual data from the 2005-2008 National Travel Survey. Models assessed associations between being a bus pass holder and active travel (walking, cycling, and use of public transport), use of buses, and walking 3 or more times per week. RESULTS Having a free pass was significantly associated with greater active travel among both disadvantaged (adjusted odds ratio [AOR] = 4.06; 95% confidence interval [CI] = 3.35, 4.86; P < .001) and advantaged groups (AOR = 4.72; 95% CI = 3.99, 5.59; P < .001); greater bus use in both disadvantaged and advantaged groups (AOR = 7.03; 95% CI = 5.53, 8.94; P < .001 and AOR = 7.11; 95% CI = 5.65, 8.94; P < .001, respectively); and greater likelihood of walking more frequently in the whole cohort (AOR = 1.15; 95% CI = 1.07, 1.12; P < .001). CONCLUSIONS Public subsidies enabling free bus travel for older persons may confer significant population health benefits through increased incidental physical activity.

Application of patient-reported outcome measures (PROMs) data to estimate cost-effectiveness of hernia surgery in England

Objectives To demonstrate potential uses of nationally collected patient-reported outcome measures (PROMs) data to estimate cost-effectiveness of hernia surgery. Design Cost-utility model populated with national PROMs, National Reference Cost and Hospital Episodes Statistics data. Setting Hospitals in England that provided elective inguinal hernia repair surgery for NHS patients between 1 April 2009 and 31 March 2010. Participants Patients >18 years undergoing NHS-funded elective hernia surgery in English hospitals who completed PROMs questionnaires. Main outcome measures Change in quality-adjusted life year (QALY) following surgery; cost per QALY of surgery by acute provider hospital; health gain and cost per QALY by surgery type received (laparoscopic or open hernia repair). Results The casemix-adjusted, discounted (at 3.5%) and degraded (over 25 years) mean change in QALYs following elective hernia repair surgery is 0.826 (95% CI, 0.793–0.859) compared to a counterfactual of no treatment. Patients undergoing laparoscopic surgery show a significantly greater gain in health-related quality of life (EQ-5D index change, 0.0915; 95% CI, 0.0850–0.0979) with an estimated gain of 0.923 QALYS (95% CI, 0.859–0.988) compared to those having open repair (EQ-5D index change, 0.0806; 95% CI, 0.0771–0.0841) at 0.817 QALYS (95% CI, 0.782–0.852). The average cost of hernia surgery in England is £1554, representing a mean cost per QALY of £1881. The mean cost of laparoscopic and open hernia surgery is equivocal (£1421 vs. £1426 respectively) but laparoscopies appear to offer higher cost-utility at £1540 per QALY, compared to £1746 per QALY for open surgery. Conclusions Routine PROMs data derived from NHS patients could be usefully analyzed to estimate health outcomes and cost-effectiveness of interventions to inform decision-making. This analysis suggests elective hernia surgery offers value-for-money, and laparoscopic repair is more clinically effective and generates higher cost-utility than open surgery.

Evaluation of clinical threshold policies for cataract surgery among English commissioners

Objectives: To ascertain if access to cataract surgery is being restricted in England and to describe any explicit threshold criteria. Methods: A survey of 151 local commissioners to explore their cataract surgery policy. A literature review identified research evidence about thresholds for cataract surgery. A checklist was devised and applied to the policies supplied by commissioners. Results: Almost half (71/151) of commissioners were restricting access to surgery and this included patients with some capacity to benefit. There was wide variation in the scope and content of the 67 policies which were available for review. Almost all (92%) commissioners use criteria that do not reflect guidance or research evidence. Conclusions: Patients who could benefit from cataract surgery are being excluded by some commissioners. Variations in policy between commissioners results in inequalities in access.

Effective smoking cessation interventions for COPD patients: a review of the evidence

Objectives To review the effectiveness of smoking cessation interventions offered to chronic obstructive pulmonary disease (COPD) patients, and identify barriers to quitting experienced by them, so that a more effective service can be developed for this group. Design A rapid systematic literature review comprising computerized searches of electronic databases, hand searches and snowballing were used to identify both published and grey literature. Setting A review of studies undertaken in north-western Europe (defined as: United Kingdom, Ireland, France, Germany, Benelux and Nordic countries). Participants COPD patients participating in studies looking at the effectiveness of smoking cessation interventions in this patient group, or exploring the barriers to quitting experienced by these patients. Method Quantitative and qualitative papers were selected according to pre-specified inclusion and exclusion criteria, critically appraised, and quantitative papers scored against the NICE Levels of Evidence standardized hierarchy. Main outcome measure Percentages of successful quitters and length of quit, assessed by self-report or biochemical analysis. Among qualitative studies, identified barriers to smoking cessation had to be explored. Results Three qualitative and 13 quantitative papers were finally selected. Effective interventions and barriers to smoking cessation were identified. Pharmacological support with Buproprion combined with counselling was significantly more efficacious in achieving prolonged abstinence than a placebo by 18.9% (95% CI 3.6–26.4%). Annual spirometry with a brief smoking cessation intervention, followed by a personal letter from a doctor, had a significantly higher ≥1 year abstinence rate at three years among COPD patient smokers, compared to smokers with normal lung function (P < 0.001; z = 3.93). Identified barriers to cessation included: patient misinformation, levels of motivation, health beliefs, and poor communication with health professionals. Conclusion Despite the public health significance of COPD, there is a lack of high-quality evidence showing which smoking cessation support methods work for these patients. This review describes three effective interventions, as well as predictors of quitting success that service providers could use to improve quit rates in this group. Areas that would benefit from urgent further research are also identified.

The Royal College of Ophthalmologists' Cataract Surgery Commissioning Guidance: executive summary

The Royal College of Ophthalmologists recently published evidence-based guidance on commissioning for cataract surgery in response to reports of wide geographical variation in access to cataract surgery in England, and the increasing use of arbitrary Snellen visual acuity thresholds to govern access to cataract surgery. This article summarises the main findings of the Commissioning Guidance and current issues surrounding cataract surgery provision in the NHS. The methodology used to develop this guidance was granted National Institute for Health and Care Excellence (NICE) accreditation in July 2015.

The cataract surgery access debate: why variation may be a good thing.

Cataract surgery carries the accolade of being one—if not the—most common elective procedure carried out by the National Health Service (NHS) in England each year1 Over the decade 2002 and 2003 to 2011 and 2012, the rate of NHS provision increased annually by 1.8%.2 In absolute terms, the NHS funded 637 episodes per 100 000 population in 2004, though the true figure is likely to be substantially higher if privately funded surgery had been included in these estimates.3 This increase broadly coincided with reduced median waiting times, which dropped from 4200 days in 1998 to o75 days in 2007, and by 2011–12 this was 59 days from specialist assessment to treatment.4,5 Reassuringly, offering more surgery appeared to result in superior access equity, with an inverse relationship between area deprivation and cataract surgery waiting times emerging.4 In 2009, it was announced that the NHS would make £20 billion savings between 2011 and 2012 and 2014 and 2015.6 These savings were to be recurrent, and found through service efficiencies, including reducing reliance on overused interventions.6,7 Although cataract surgery is, in absolute terms, considered clinically very effective, questions are increasingly being raised about whether it is being overor inappropriately used, particularly in mild cases where the risks of surgery may outweigh any potential health benefits.3,8,9 For example, at a population level, the risk of visual loss among patients with better presurgery visual acuity (VA) is not inconsiderable: 6.9% of patients with a baseline VA of ≤ 6/6 Snellen (approximation of ≤ 0.00 logMAR) and 5.6% of those with a VA of ≤ 6/9 Snellen (approximation of ≤ 0.18 logMAR) are left with poorer vision following cataract removal.10 This is more conservative than an earlier study which found the majority (64.3%) of patients with preoperative acuities of ≤ 6/7.5 Snellen had the same or worse vision following surgery.11 The real challenge, then, is ensuring that appropriate candidates for surgery receive it in a timely manner, while inappropriate ones are excluded or deferred. Improving the quality and appropriateness of referrals to specialist treatment could both improve patient experience and reduce costs by reducing unnecessary consultations, as well as widening access to and speed of treatment for those that need it.12 Quite apart from the harm operating on the wrong patients represents, there could also be a considerable opportunity cost. In other words, the NHS could be making more effective use of its shrinking resources by avoiding overuse in cataract surgery and putting resources towards other health purchasing,9 such as targeting its spending at relatively more effective surgeries. Indeed, a 2011 survey of Primary Care Trusts (PCTs) found that half (47%) had current policies in place to manage access to cataract surgery.13 The financial year 2011–12, saw a statistically significant drop of 4.8% in the overall rate of cataract surgery undertaken by the NHS, a decline that coincided with the first year of financial austerity.2 The pattern, though, was varied among commissioning organisations: while a third (30.5%) of PCTs had reduced rates of cataract surgery, about one-sixth (13.2%) showed increases.2 Reassuringly, though, there were no discernable differences in surgery rates between more or less affluent areas, suggesting inequity is still not a particular concern.2 What the data cannot currently tell is whether the observed reductions coincided with fewer inappropriate surgeries. There is a growing public perception that a ‘postcode lottery’ is emerging, with patients being unfairly denied access to cataract surgery.14,15 Assuring commissioners, clinicians and the public that any reductions in procedure rates actually coincide with reduced episodes of inappropriate Department of Primary Care and Public Health, School of Public Health, Faculty of Medicine, Imperial College London, London, UK