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Achten J, Marques EMR, Pinedo-Villanueva R, Whitehouse MR, Eardley WGP, Costa ML, Kearney RS, Keene DJ, Griffin XL. The FAME trial study protocol: In younger adults with unstable ankle fractures treated with close contact casting, is ankle function not worse than those treated with surgical intervention? Bone Jt Open 2024; 5:184-201. [PMID: 38447595 PMCID: PMC10924289 DOI: 10.1302/2633-1462.53.bjo-2023-0099.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
Aims Ankle fracture is one of the most common musculoskeletal injuries sustained in the UK. Many patients experience pain and physical impairment, with the consequences of the fracture and its management lasting for several months or even years. The broad aim of ankle fracture treatment is to maintain the alignment of the joint while the fracture heals, and to reduce the risks of problems, such as stiffness. More severe injuries to the ankle are routinely treated surgically. However, even with advances in surgery, there remains a risk of complications; for patients experiencing these, the associated loss of function and quality of life (Qol) is considerable. Non-surgical treatment is an alternative to surgery and involves applying a cast carefully shaped to the patient's ankle to correct and maintain alignment of the joint with the key benefit being a reduction in the frequency of common complications of surgery. The main potential risk of non-surgical treatment is a loss of alignment with a consequent reduction in ankle function. This study aims to determine whether ankle function, four months after treatment, in patients with unstable ankle fractures treated with close contact casting is not worse than in those treated with surgical intervention, which is the current standard of care. Methods This trial is a pragmatic, multicentre, randomized non-inferiority clinical trial with an embedded pilot, and with 12 months clinical follow-up and parallel economic analysis. A surveillance study using routinely collected data will be performed annually to five years post-treatment. Adult patients, aged 60 years and younger, with unstable ankle fractures will be identified in daily trauma meetings and fracture clinics and approached for recruitment prior to their treatment. Treatments will be performed in trauma units across the UK by a wide range of surgeons. Details of the surgical treatment, including how the operation is done, implant choice, and the recovery programme afterwards, will be at the discretion of the treating surgeon. The non-surgical treatment will be close-contact casting performed under anaesthetic, a technique which has gained in popularity since the publication of the Ankle Injury Management (AIM) trial. In all, 890 participants (445 per group) will be randomly allocated to surgical or non-surgical treatment. Data regarding ankle function, QoL, complications, and healthcare-related costs will be collected at eight weeks, four and 12 months, and then annually for five years following treatment. The primary outcome measure is patient-reported ankle function at four months from treatment. Anticipated impact The 12-month results will be presented and published internationally. This is anticipated to be the only pragmatic trial reporting outcomes comparing surgical with non-surgical treatment in unstable ankle fractures in younger adults (aged 60 years and younger), and, as such, will inform the National Institute for Health and Care Excellence (NICE) 'non-complex fracture' recommendations at their scheduled update in 2024. A report of long-term outcomes at five years will be produced by January 2027.
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Affiliation(s)
- Juul Achten
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Rafael Pinedo-Villanueva
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | | | - Matthew L. Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - David J. Keene
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Xavier L. Griffin
- Barts Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
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Baji P, Barbosa EC, Heaslip V, Sangar B, Tbaily L, Martin R, Docherty S, Allen H, Hayward C, Marques EMR. Use of removable support boot versus cast for early mobilisation after ankle fracture surgery: cost-effectiveness analysis and qualitative findings of the Ankle Recovery Trial (ART). BMJ Open 2024; 14:e073542. [PMID: 38216176 PMCID: PMC10810042 DOI: 10.1136/bmjopen-2023-073542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 11/13/2023] [Indexed: 01/14/2024] Open
Abstract
OBJECTIVES To estimate the cost-effectiveness of using a removable boot versus a cast following ankle fracture from the National Health Service and Personal Social Services (NHS+PSS) payer and societal perspectives and explore the impact of both treatments on participants' activities of daily living. DESIGN Cost-effectiveness analyses and qualitative interviews performed alongside a pragmatic multicentre randomised controlled trial. SETTING Eight UK NHS secondary care trusts. PARTICIPANTS 243 participants (60.5% female, on average 48.2 years of age (SD 16.4)) with ankle fracture. Qualitative interviews with 16 participants. Interventions removable air boot versus plaster cast 2 weeks after surgery weight bearing as able with group-specific exercises. PRIMARY AND SECONDARY OUTCOME MEASURES Quality-adjusted life years (QALYs) estimated from the EQ-5D-5L questionnaire, costs and incremental net monetary benefit statistics measured 12 weeks after surgery, for a society willing-to-pay £20 000 per QALY. RESULTS Care in the boot group cost, on average, £88 (95% CI £22 to £155) per patient more than in the plaster group from the NHS+PSS perspective. When including all societal costs, the boot saved, on average, £676 per patient (95% CI -£337 to £1689). Although there was no evidence of a QALY difference between the groups (-0.0020 (95% CI -0.0067 to 0.0026)), the qualitative findings suggest participants felt the boot enhanced their quality of life. Patients in the boot felt more independent and empowered to take on family responsibilities and social activities. CONCLUSIONS While the removable boot is slightly more expensive than plaster cast for the NHS+PSS payer at 12 weeks after surgery, it reduces productivity losses and the need for informal care while empowering patients. Given that differences in QALYs and costs to the NHS are small, the decision to use a boot or plaster following ankle surgery could be left to patients' and clinicians' preferences. TRIAL REGISTRATION NUMBER ISRCTN15497399, South Central-Hampshire A Research Ethics Committee (reference 14/SC/1409).
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Affiliation(s)
- Petra Baji
- Musculoskeletal Research Unit, Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Estela C Barbosa
- Musculoskeletal Research Unit, Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, UK
- UKPRP VISION Consortium, London, UK
| | - Vanessa Heaslip
- School of Nursing and Society, University of Salford, Salford, UK
- Department of Social Science, University of Stavanger, Stavanger, Norway
| | - Bob Sangar
- University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Lee Tbaily
- University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Rachel Martin
- University Hospitals Dorset NHS Foundation Trust, Poole, UK
| | - Sharon Docherty
- Department of Medical Science and Public Health, Bournemouth University, Poole, UK
| | - Helen Allen
- Bournemouth University Clinical Research Unit, Bournemouth University, Poole, UK
| | - Christopher Hayward
- Peninsula Clinical Trials Unit, Plymouth University, Plymouth, UK
- Exeter Clinical Trials Unit, University of Exeter, Exeter, UK
| | - Elsa M R Marques
- Musculoskeletal Research Unit, Bristol Medical School, Translational Health Sciences, University of Bristol, Bristol, UK
- NIHR Biomedical Research Centre, University of Bristol, Bristol, UK
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Baji P, Patel R, Judge A, Johansen A, Griffin J, Chesser T, Griffin XL, Javaid MK, Barbosa EC, Ben-Shlomo Y, Marques EMR, Gregson CL. Organisational factors associated with hospital costs and patient mortality in the 365 days following hip fracture in England and Wales (REDUCE): a record-linkage cohort study. Lancet Healthy Longev 2023; 4:e386-e398. [PMID: 37442154 DOI: 10.1016/s2666-7568(23)00086-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Hip fracture care delivery varies between hospitals, which might explain variations in patient outcomes and health costs. The aim of this study was to identify hospital-level organisational factors associated with long-term patient outcomes and costs after hip fracture. METHODS REDUCE was a record-linkage cohort study in which national databases for all patients aged 60 years and older who sustained a hip fracture in England and Wales were linked with hospital metrics from 18 organisational data sources. Multilevel models identified organisational factors associated with the case-mix adjusted primary outcomes: cumulative all-cause mortality, days spent in hospital, and inpatient costs over 365 days after hip fracture. FINDINGS Between April 1, 2016, and March 31, 2019, 178 757 patients with an index hip fracture were identified from 172 hospitals in England and Wales. 126 278 (70·6%) were female, 52 479 (29·4%) were male, and median age was 84 years (IQR 77-89) in England and 83 years (77-89) in Wales. 365 days after hip fracture, 50 354 (28·2%) patients had died. Patients spent a median 21 days (IQR 11-41) in hospital, incurring costs of £14 642 (95% CI 14 600-14 683) per patient, ranging from £10 867 (SD 5880) to £23 188 (17 223) between hospitals. 11 organisational factors were independently associated with mortality, 24 with number of days in hospital, and 25 with inpatient costs. Having all patients assessed by an orthogeriatrician within 72 h of admission was associated with a mean cost saving of £529 (95% CI 148-910) per patient and a lower 365-day mortality (odds ratio 0·85 [95% CI 0·76-0·94]). Consultant orthogeriatrician attendance at clinical governance meetings was associated with cost savings of £356 (95% CI 188-525) and 1·47 fewer days (95% CI 0·89-2·05) in the hospital in the 365 days after hip fracture per patient. The provision of physiotherapy to patients on weekends was associated with a cost saving of £676 (95% CI 67-1285) per patient and with 2·32 fewer days (0·35-4·29) in hospital in the 365 days after hip fracture. INTERPRETATION Multiple, potentially modifiable hospital-level organisational factors associated with important clinical outcomes and inpatient costs were identified that should inform initiatives to improve the effectiveness and efficiency of hip fracture services. FUNDING Versus Arthritis.
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Affiliation(s)
- Petra Baji
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Corvinus University of Budapest, Budapest, Hungary.
| | - Rita Patel
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; NIHR Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Antony Johansen
- Division of Population Medicine, School of Medicine, Cardiff University and University Hospital of Wales, Cardiff, UK; National Hip Fracture Database, Royal College of Physicians, London, UK
| | | | - Tim Chesser
- Department of Trauma and Orthopaedics, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Xavier L Griffin
- Barts Bone and Joint Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK; Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Estela C Barbosa
- Violence and Society Centre, School of Policy and Global Affairs, City University of London, London, UK; UKPRP VISION Consortium, London, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; National Institute for Health and Care Research Applied Research Collaboration West at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Elsa M R Marques
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; NIHR Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Celia L Gregson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Older People's Unit, Royal United Hospital NHS Foundation Trust Bath, Bath, UK
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Patel R, Judge A, Johansen A, Marques EMR, Chesser T, Griffin XL, Javaid MK, Ben-Shlomo Y, Gregson CL. Patients' recovery of mobility and return to original residence after hip fracture are associated with multiple modifiable components of hospital service organisation: the REDUCE record-linkage cohort study in England and Wales. BMC Geriatr 2023; 23:459. [PMID: 37501122 PMCID: PMC10375618 DOI: 10.1186/s12877-023-04038-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/12/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Hip fractures are devastating injuries causing disability, dependence, and institutionalisation, yet hospital care is highly variable. This study aimed to determine hospital organisational factors associated with recovery of mobility and change in patient residence after hip fracture. METHODS A cohort of patients aged 60 + years in England and Wales, who sustained a hip fracture from 2016 to 2019 was examined. Patient-level Hospital Episodes Statistics, National Hip Fracture Database, and mortality records were linked to 101 factors derived from 18 hospital-level organisational metrics. After adjustment for patient case-mix, multilevel models were used to identify organisational factors associated with patient residence at discharge, and mobility and residence at 120 days after hip fracture. RESULTS Across 172 hospitals, 165,350 patients survived to discharge, of whom 163,230 (99%) had post-hospital discharge destination recorded. 18,323 (11%) died within 120 days. Among 147,027 survivors, 58,344 (40%) across 143 hospitals had their residence recorded, and 56,959 (39%) across 140 hospitals had their mobility recorded, at 120 days. Nineteen organisational factors independently predicted residence on hospital discharge e.g., return to original residence was 31% (95% confidence interval, CI:17-43%) more likely if the anaesthetic lead for hip fracture had time allocated in their job plan, and 8-13% more likely if hip fracture service clinical governance meetings were attended by an orthopaedic surgeon, physiotherapist or anaesthetist. Seven organisational factors independently predicted residence at 120 days. Patients returning to their pre-fracture residence was 26% (95%CI:4-42%) more likely if hospitals had a dedicated hip fracture ward, and 20% (95%CI:8-30%) more likely if treatment plans were proactively discussed with patients and families on admission. Seventeen organisational factors predicted mobility at 120 days. More patients re-attained their pre-fracture mobility in hospitals where (i) care involved an orthogeriatrician (15% [95%CI:1-28%] improvement), (ii) general anaesthesia was usually accompanied by a nerve block (7% [95%CI:1-12%], and (iii) bedside haemoglobin testing was routine in theatre recovery (13% [95%CI:6-20%]). CONCLUSIONS Multiple, potentially modifiable, organisational factors are associated with patient outcomes up to 120 days after a hip fracture, these factors if causal should be targeted by service improvement initiatives to reduce variability, improve hospital hip fracture care, and maximise patient independence.
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Affiliation(s)
- Rita Patel
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Antony Johansen
- School of Medicine, Cardiff University and University Hospital of Wales, Cardiff, UK
- National Hip Fracture Database, Royal College of Physicians, London, UK
| | - Elsa M R Marques
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK
- NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Tim Chesser
- Department of Trauma and Orthopaedics, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Xavier L Griffin
- Barts Bone and Joint Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research (NIHR) Applied Research Collaboration West (ARC West) at University of Bristol and United Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Celia L Gregson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK.
- Older People's Unit, Royal United Hospital NHS Foundation Trust Bath, Combe Park, Bath, UK.
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Barbosa EC, Wylde V, Thorn J, Sanderson E, Lenguerrand E, Artz N, Blom AW, Marques EMR. Cost-Effectiveness of Group-Based Outpatient Physical Therapy After Total Knee Replacement: Results From the Economic Evaluation Alongside the ARENA Multicenter Randomized Controlled Trial. Arthritis Care Res (Hoboken) 2022; 74:1970-1977. [PMID: 35468266 PMCID: PMC10087974 DOI: 10.1002/acr.24903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 02/09/2022] [Accepted: 04/14/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess the cost-utility and cost-effectiveness of a group-based outpatient physical therapy intervention delivered 6 weeks after primary total knee replacement (TKR) compared with usual care, alongside the Activity-Orientated Rehabilitation Following Knee Arthroplasty (ARENA) multicenter, randomized, controlled trial. METHODS The economic analyses were performed from the perspective of the health and social care payer. We collected resource use for health and social care and productivity losses and patient outcomes for 12 months after surgery to derive costs and quality-adjusted life years (QALYs). Results were expressed in incremental cost-effectiveness ratios (ICERs), and incremental net monetary benefit statistics (INMBs) for a society willingness-to-pay (WTP) threshold of £20,000 per QALY gained, with sensitivity analyses to model specification and perspective. RESULTS The cost of the ARENA physical therapy classes was mean ± SD £179 ± 39 per patient. Treatment in the year following surgery cost was, on average, £1,739 (95% confidence interval [95% CI] -£742, £4,221) per patient in the intervention group (n = 89), which was an additional £346 (95% CI £38, £653) per patient compared with usual care (n = 91) (£1,393 [95% CI -£780, £3,568]). QALY benefits were 0.0506 higher (95% CI 0.009, 0.09) in the intervention group, corresponding to an additional 19 days in "perfect health." The ICER for the intervention group was £6,842 per QALY gained, and the INMB was £665 (95% CI £139, £1,191), with a 92% probability of being cost-effective, and no less than 73% in all sensitivity analysis scenarios. CONCLUSION The addition of group-based outpatient physical therapy classes to usual care improves quality of life and is a cost-effective treatment option following TKR for a society WTP threshold of £20,000 per QALY gained.
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Affiliation(s)
| | - Vikki Wylde
- University of Bristol, Bristol Medical School and NIHR Bristol Medical Research Centre, Bristol, UK
| | - Joanna Thorn
- University of Bristol, Bristol Medical School, Bristol, UK
| | | | | | - Neil Artz
- University of Gloucestershire, Gloucester, UK
| | - Ashley W Blom
- University of Bristol, Bristol Medical School and NIHR Bristol Medical Research Centre, Bristol, UK
| | - Elsa M R Marques
- University of Bristol, Bristol Medical School and NIHR Bristol Medical Research Centre, Bristol, UK
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Patel R, Judge A, Johansen A, Marques EMR, Griffin J, Bradshaw M, Drew S, Whale K, Chesser T, Griffin XL, Javaid MK, Ben-Shlomo Y, Gregson CL. Multiple hospital organisational factors are associated with adverse patient outcomes post-hip fracture in England and Wales: the REDUCE record-linkage cohort study. Age Ageing 2022; 51:6679179. [PMID: 36041740 PMCID: PMC9427326 DOI: 10.1093/ageing/afac183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/23/2022] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Despite established standards and guidelines, substantial variation remains in the delivery of hip fracture care across the United Kingdom. We aimed to determine which hospital-level organisational factors predict adverse patient outcomes in the months following hip fracture. METHODS We examined a national record-linkage cohort of 178,757 patients aged ≥60 years who sustained a hip fracture in England and Wales in 2016-19. Patient-level hospital admissions datasets, National Hip Fracture Database and mortality data were linked to metrics from 18 hospital-level organisational-level audits and reports. Multilevel models identified organisational factors, independent of patient case-mix, associated with three patient outcomes: length of hospital stay (LOS), 30-day all-cause mortality and emergency 30-day readmission. RESULTS Across hospitals mean LOS ranged from 12 to 41.9 days, mean 30-day mortality from 3.7 to 10.4% and mean readmission rates from 3.7 to 30.3%, overall means were 21.4 days, 7.3% and 15.3%, respectively. In all, 22 organisational factors were independently associated with LOS; e.g. a hospital's ability to mobilise >90% of patients promptly after surgery predicted a 2-day shorter LOS (95% confidence interval [CI]: 1.2-2.6). Ten organisational factors were independently associated with 30-day mortality; e.g. discussion of patient experience feedback at clinical governance meetings and provision of prompt surgery to >80% of patients were each associated with 10% lower mortality (95%CI: 5-15%). Nine organisational factors were independently associated with readmissions; e.g. readmissions were 17% lower if hospitals reported how soon community therapy would start after discharge (95%CI: 9-24%). CONCLUSIONS Receipt of hip fracture care should be reliable and equitable across the country. We have identified multiple, potentially modifiable, organisational factors associated with important patient outcomes following hip fracture.
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Affiliation(s)
- Rita Patel
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK,NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, UK
| | - Antony Johansen
- Division of Population Medicine, School of Medicine, Cardiff University and University Hospital of Wales, Cardiff, UK,National Hip Fracture Database, Royal College of Physicians, London, UK
| | - Elsa M R Marques
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK,NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, UK
| | - Jill Griffin
- Clinical & Operations Directorate, Royal Osteoporosis Society, Bath, UK
| | - Marianne Bradshaw
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Drew
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Katie Whale
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK,NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, UK
| | - Tim Chesser
- Department of Trauma and Orthopaedics, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Xavier L Griffin
- Barts Bone and Joint Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK,Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Celia L Gregson
- Address correspondence to: Celia L. Gregson, Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK. Tel: +44 7815102351.
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Drew S, Fox F, Gregson CL, Patel R, Judge A, Johansen A, Marques EMR, Barbosa EC, Griffin J, Bradshaw M, Whale K, Chesser T, Griffin XL, Javaid MK, Ben-Shlomo Y, Gooberman-Hill R. 995 MULTIPLE ORGANISATIONAL FACTORS IMPROVE MULTI-DISCIPLINARY CARE DELIVERY TO PATIENTS WITH HIP FRACTURES: A QUALITATIVE STUDY. Age Ageing 2022. [DOI: 10.1093/ageing/afac126.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Hip fractures are devastating injuries which incur high healthcare costs. Despite national standards and guidelines, there is substantial variation in hospital delivery of hip fracture care and in patient outcomes. This study aimed to understand organisational processes that facilitate successful delivery of hip fracture services.
Method
Forty qualitative interviews were conducted with healthcare professionals involved in delivering hip fracture care at four English hospitals. Interview data were supplemented with documentary analysis of 23 anonymised British Orthopaedic Association hospital-initiated peer-review reports of services. Data were analysed thematically, with themes transposed onto key components of the care pathway.
Results
We identified multiple aspects of service organisation that facilitated good care delivery. At admission, standardisation of training in nerve block administration impacted care delivery. During hospital stays, service delivery was improved by integrated, shared-care between orthopaedics and orthogeriatrics, and by strategies to improve trauma list efficiency. Adequately staffed orthogeriatric services and the ‘right’ skills and seniority mix were important to holistic care provision. Placing patients on designated hip fracture wards concentrated staff expertise. Collaborative working was achieved through multi-disciplinary team (MDT) meetings between key staff, protocols and care pathways that defined roles and responsibilities, MDT documentation, ‘joined-up’ IT systems within hospitals and with primary care, and shared working spaces such as shared offices and onwards. Trauma and hip fracture coordinators organised care processes and provided a valuable central point of contact within teams. Nominated leads, representing diverse specialties, worked together in MDT planning meetings to develop joint protocols, establish audit priorities, and agree shared goals. Routine, comprehensive monitoring and evaluation of service delivery, with findings shared throughout the MDT, was beneficial.
Conclusion
Our study has characterised potentially modifiable elements of successful hip fracture service delivery. Findings are intended to help services overcome organisational barriers towards delivery of high-quality hip fracture services.
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Affiliation(s)
| | | | | | | | | | - A Johansen
- Cardiff University and University Hospital of Wales
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Patel R, Judge A, Johansen A, Marques EMR, Barbosa EC, Griffin J, Bhimjiyani A, Bradshaw M, Whale K, Drew, Gooberman-Hill R, Chesser T, Griffin XL, Javaid MK, Ben-Shlomo Y, Gregson CL. 946 MULTIPLE ORGANISATIONAL FACTORS ARE ASSOCIATED WITH ADVERSE PATIENT OUTCOMES POST HIP FRACTURE IN HOSPITALS IN ENGLAND & WALES. Age Ageing 2022. [DOI: 10.1093/ageing/afac124.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Older adults who sustain a hip fracture require complex multidisciplinary care, which can challenge organisational structures within hospitals. Despite standards and guidelines, substantial variation remains in hip fracture care delivery across the UK. We aimed to determine which hospital-level organisational factors predict adverse patient outcomes in the post injury period.
Method
A cohort of 178,757 patients aged 60+ years in England and Wales (2016–19) who sustained a hip fracture was examined. Patient-level Hospital Episodes Statistics, National Hip Fracture Database, and mortality data were linked to metrics from 18 hospital-level organisational audits/reports/series. Multilevel models determined the organisational factors, independent of patient case-mix, associated with three patient outcomes: length of hospital stay (LOS), 30-day all-cause mortality, and emergency 30-day readmission.
Results
Overall LOS was mean 21 days (standard deviation, 20); 13,126 (7.3%) died within 30-days; and 25,239 (15.3%) were readmitted. 25 organisational factors independently predicted LOS: for example, a hospital’s ability to promptly mobilise ≥90% of patients was associated with a 2-day (95%CI:1.3–2.7) shorter LOS, and hospitals where all patients received orthogeriatric assessment within 72 hours of admission had mean 1.5-day (95%CI:0.6–2.3) shorter LOS. Ten organisational factors independently predicted 30-day mortality: providing prompt surgery (≤36 hours from admission) to >80% patients was associated with the same 10% reduction in mortality (95%CI:4–15%), as was discussion of ‘patient experience’ feedback at clinical governance meetings (95%CI:5–15%). Nine organisational factors independently predicted readmission: knowledge of time from discharge to start of community therapy was associated with 17% (95%CI:9–24%) lower readmission rates. Organisational delivery of clinical governance, surgery, and physiotherapy were associated with all outcomes.
Conclusion
Multiple, potentially modifiable, organisational factors are associated with important patient outcomes post-hip fracture. These factors, if causal, indicate auditable components of hospital care where interventions can be targeted to reduce variability in hip fracture care delivery, to improve patient outcomes.
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Affiliation(s)
| | | | - A Johansen
- Cardiff University and University Hospital of Wales
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9
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Patel R, Drew S, Johansen A, Chesser T, Javaid MK, Griffin XL, Jones T, Griffin J, Bradshaw M, Whale K, Barbosa EC, Marques EMR, Ben-Shlomo Y, Gooberman-Hill R, Judge A, Gregson CL. REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE): protocol for a mixed-methods study. BMJ Open 2021; 11:e049763. [PMID: 34011603 PMCID: PMC8137248 DOI: 10.1136/bmjopen-2021-049763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Substantial variation in the delivery of hip fracture care, and patient outcomes persists between hospitals, despite established UK national standards and guidelines. Patients' outcomes are partly explained by patient-level risk factors, but it is hypothesised that organisational-level factors account for the persistence of unwarranted variation in outcomes. The mixed-methods REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE) study, aims to determine key organisational factors to target to improve patient care. METHODS AND ANALYSIS Quantitative analysis will assess the outcomes of patients treated at 172 hospitals in England and Wales (2016-2019) using National Hip Fracture Database data combined with English Hospital Episodes Statistics; Patient Episode Database for Wales; Civil Registration (deaths) and multiple organisational-level audits to characterise each service provider. Statistical analyses will identify which organisational factors explain variation in patient outcomes, and typify care pathways with high-quality consistent patient outcomes. Documentary analysis of 20 anonymised British Orthopaedic Association hospital-initiated peer-review reports, and qualitative interviews with staff from four diverse UK hospitals providing hip fracture care, will identify barriers and facilitators to care delivery. The COVID-19 pandemic has posed a major challenge to the resilience of services and interviews will explore strategies used to adapt and innovate. This system-wide understanding will inform the development, in partnership with key national stakeholders, of an 'Implementation Toolkit' to inform and improve commissioning and delivery of hip fracture services. ETHICS AND DISSEMINATION This study was approved: quantitative study by London, City and East Research Ethics Committee (20/LO/0101); and qualitative study by Faculty of Health Sciences University of Bristol Research Ethics Committee (Ref: 108284), National Health Service (NHS) Health Research Authority (20/HRA/71) and each NHS Trust provided Research and Development approval. Findings will be disseminated through scientific conferences, peer-reviewed journals and online workshops.
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Affiliation(s)
- Rita Patel
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Drew
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Antony Johansen
- Division of Population Medicine, School of Medicine, Cardiff University and University Hospital of Wales, Cardiff, UK
- National Hip Fracture Database, Royal College of Physicians, London, UK
| | - Tim Chesser
- Department of Trauma and Orthopaedics, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Xavier L Griffin
- Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Tim Jones
- Clinical & Operations Directorate, Royal Osteoporosis Society, Bath, UK
| | - Jill Griffin
- Clinical & Operations Directorate, Royal Osteoporosis Society, Bath, UK
| | - Marianne Bradshaw
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Katie Whale
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Estela Capelas Barbosa
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Elsa M R Marques
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Andrew Judge
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Celia L Gregson
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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10
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Marques EMR, Dennis J, Beswick AD, Higgins J, Thom H, Welton N, Burston A, Hunt L, Whitehouse MR, Blom AW. Choice between implants in knee replacement: protocol for a Bayesian network meta-analysis, analysis of joint registries and economic decision model to determine the effectiveness and cost-effectiveness of knee implants for NHS patients-The KNee Implant Prostheses Study (KNIPS). BMJ Open 2021; 11:e040205. [PMID: 33408201 PMCID: PMC7789438 DOI: 10.1136/bmjopen-2020-040205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 11/16/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Knee replacements are highly successful for many people, but if a knee replacement fails, revision surgery is generally required. Surgeons and patients may choose from a range of implant components and combinations that make up knee replacement constructs, all with potential implications for how long a knee replacement will last. To inform surgeon and patient decisions, a comprehensive synthesis of data from randomised controlled trials is needed to evaluate the effects of different knee replacement implants on overall construct survival. Due to limited follow-up in trials, joint registry analyses are also needed to assess the long-term survival of constructs. Finally, economic modelling can identify cost-effective knee replacement constructs for different patient groups. METHODS AND ANALYSIS In this protocol, we describe systematic reviews and network meta-analyses to synthesise evidence on the effectiveness of knee replacement constructs used in total and unicompartmental knee replacement and analyses of two national joint registries to assess long-term outcomes. Knee replacement constructs are defined by bearing materials and mobility, constraint, fixation and patella resurfacing. For men and women in different age groups, we will compare the lifetime cost-effectiveness of knee replacement constructs. ETHICS AND DISSEMINATION Systematic reviews are secondary analyses of published data with no ethical approval required. We will design a common joint registry analysis plan and provide registry representatives with information for submission to research or ethics committees. The project has been assessed by the National Health Service (NHS) REC committee and does not require ethical review.Study findings will be disseminated to clinicians, researchers and administrators through open access articles, presentations and websites. Specific UK-based groups will be informed of results including National Institute for Health Research and National Institute for Health and Care Excellence, as well as international orthopaedic associations and charities. Effective dissemination to patients will be guided by our patient-public involvement group and include written lay summaries and infographics. PROSPERO REGISTRATION NUMBER CRD42019134059 and CRD42019138015.
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Affiliation(s)
- Elsa M R Marques
- Musculoskeletal Research Unit, Bristol Medical School, Bristol, UK
| | - Jane Dennis
- Musculoskeletal Research Unit, Bristol Medical School, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Bristol Medical School, Bristol, UK
| | - Julian Higgins
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Howard Thom
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Nicky Welton
- Department of Population Health Sciences, Bristol Medical School, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, Bristol Medical School, Bristol, UK
| | - Linda Hunt
- Musculoskeletal Research Unit, Bristol Medical School, Bristol, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Bristol Medical School, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, Bristol Medical School, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol, Bristol, UK
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11
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Williamson H, Hamlet C, White P, Marques EMR, Paling T, Cadogan J, Perera R, Rumsey N, Hayward L, Harcourt D. A Web-Based Self-Help Psychosocial Intervention for Adolescents Distressed by Appearance-Affecting Conditions and Injuries (Young Persons' Face IT): Feasibility Study for a Parallel Randomized Controlled Trial. JMIR Ment Health 2019; 6:e14776. [PMID: 31755870 PMCID: PMC6898888 DOI: 10.2196/14776] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 09/04/2019] [Accepted: 09/08/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Disfigurement (visible difference) from wide-ranging congenital or acquired conditions, injuries, or treatments can negatively impact adolescents' psychological well-being, education and health behaviours. Alongside medical interventions, appearance-specific cognitive behavioural and social skills training to manage stigma and appearance anxiety may improve psychosocial outcomes. YP Face IT (YPF), is a Web-based seven session self-help program plus booster quiz, utilising cognitive behavioural and social skills training for young people (YP) struggling with a visible difference. Co-designed by adolescents and psychologists, it includes interactive multimedia and automated reminders to complete sessions/homework. Adolescents access YPF via a health professional who determines its suitability and remotely monitors clients' usage. OBJECTIVE To establish the feasibility of evaluating YPF for 12-17 year olds self-reporting appearance-related distress and/or bullying associated with a visible difference. METHODS Randomized controlled trial with nested qualitative and economic study evaluating YPF compared with usual care (UC). Feasibility outcomes included: viability of recruiting via general practitioner (GP) practices (face to face and via patient databases) and charity advertisements; intervention acceptability and adherence; feasibility of study and data collection methods; and health professionals' ability to monitor users' online data for safeguarding issues. Primary psychosocial self-reported outcomes collected online at baseline, 13, 26, and 52 weeks were as follows: appearance satisfaction (Appearance Subscale from Mendleson et al's (2001) Body Esteem Scale); social anxiety (La Greca's (1999) Social Anxiety Scale for Adolescents). Secondary outcomes were; self-esteem; romantic concerns; perceived stigmatization; social skills and healthcare usage. Participants were randomised using remote Web-based allocation. RESULTS Thirteen charities advertised the study yielding 11 recruits, 13 primary care practices sent 687 invitations to patients on their databases with a known visible difference yielding 17 recruits (2.5% response rate), 4 recruits came from GP consultations. Recruitment was challenging, therefore four additional practices mass-mailed 3,306 generic invitations to all 12-17 year old patients yielding a further 15 participants (0.5% response rate). Forty-seven YP with a range of socioeconomic backgrounds and conditions were randomised (26% male, 91% white, mean age 14 years (SD 1.7)); 23 to YPF, 24 to UC). At 52 weeks, 16 (70%) in the intervention and 20 (83%) in UC groups completed assessments. There were no intervention-related adverse events; most found YPF acceptable with three withdrawing because they judged it was for higher-level concerns; 12 (52%) completed seven sessions. The study design was acceptable and feasible, with multiple recruitment strategies. Preliminary findings indicate no changes from baseline in outcome measures among the UC group and positive changes in appearance satisfaction and fear of negative evaluation among the YPF group when factoring in baseline scores and intervention adherence. CONCLUSIONS YPF is novel, safe and potentially helpful. Its full psychosocial benefits should be evaluated in a large-scale RCT, which would be feasible with wide-ranging recruitment strategies. TRIAL REGISTRATION ISRCTN registry ISRCTN40650639; http://www.isrctn.com/ISRCTN40650639.
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Affiliation(s)
- Heidi Williamson
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
| | - Claire Hamlet
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
| | - Paul White
- Faculty of Environment and Technology, University of the West of England, Bristol, United Kingdom
| | - Elsa M R Marques
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Thomas Paling
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Julia Cadogan
- University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Rohan Perera
- Bristol Clinical Commissioning Group, Bristol, United Kingdom
| | - Nichola Rumsey
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
| | | | - Diana Harcourt
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, United Kingdom
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12
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Ellis-Hill C, Thomas S, Gracey F, Lamont-Robinson C, Cant R, Marques EMR, Thomas PW, Grant M, Nunn S, Paling T, Thomas C, Werson A, Galvin KT, Reynolds F, Jenkinson D. HeART of Stroke: randomised controlled, parallel-arm, feasibility study of a community-based arts and health intervention plus usual care compared with usual care to increase psychological well-being in people following a stroke. BMJ Open 2019; 9:e021098. [PMID: 30852528 PMCID: PMC6429750 DOI: 10.1136/bmjopen-2017-021098] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION People often experience distress following stroke due to fundamental challenges to their identity. OBJECTIVES To evaluate (1) the acceptability of 'HeART of Stroke' (HoS), a community-based arts and health group intervention, to increase psychological well-being; and (2) the feasibility of a definitive randomised controlled trial (RCT). DESIGN Two-centre, 24-month, parallel-arm RCT with qualitative and economic components. Randomisation was stratified by centre and stroke severity. Participant blinding was not possible. Outcome assessment blinding was attempted. SETTING Community. PARTICIPANTS Community-dwelling adults ≤2 years poststroke recruited via hospital clinical teams/databases or community stroke/rehabilitation teams. INTERVENTIONS Artist-facilitated arts and health group intervention (HoS) (ten 2-hour sessions over 14 weeks) plus usual care (UC) versus UC. OUTCOMES The outcomes were self-reported measures of well-being, mood, capability, health-related quality of life, self-esteem and self-concept (baseline and 5 months postrandomisation). Key feasibility parameters were gathered, data collection methods were piloted, and participant interviews (n=24) explored the acceptability of the intervention and study processes. RESULTS Despite a low recruitment rate (14%; 95% CI 11% to 18%), 88% of the recruitment target was met, with 29 participants randomised to HoS and 27 to UC (57% male; mean (SD) age=70 (12.1) years; time since stroke=9 (6.1) months). Follow-up data were available for 47 of 56 (84%; 95% CI 72% to 91%). Completion rates for a study-specific resource use questionnaire were 79% and 68% (National Health Service and societal perspectives). Five people declined HoS postrandomisation; of the remaining 24 who attended, 83% attended ≥6 sessions. Preliminary effect sizes for candidate primary outcomes were in the direction of benefit for the HoS arm. Participants found study processes acceptable. The intervention cost an estimated £456 per person and was well-received (no intervention-related serious adverse events were reported). CONCLUSIONS Findings from this first community-based study of an arts and health intervention for people poststroke suggest a definitive RCT is feasible. Recruitment methods will be revised. TRIAL REGISTRATION NUMBER ISRCTN99728983.
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Affiliation(s)
- Caroline Ellis-Hill
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
| | - Sarah Thomas
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
| | - Fergus Gracey
- Department of Clinical Psychology, University of East Anglia, Norwich, UK
- The Oliver Zangwill Centre for Neuropsychological Rehabilitation, Cambridgeshire Community Services NHS Trust, Ely, UK
| | | | - Robin Cant
- Service User, (formerly of Canterbury Christ Church University), Canterbury, Kent, UK
| | | | - Peter W Thomas
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
| | - Mary Grant
- Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Samantha Nunn
- The Oliver Zangwill Centre for Neuropsychological Rehabilitation, Cambridgeshire Community Services NHS Trust, Ely, UK
| | - Thomas Paling
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Charlotte Thomas
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
| | - Alessa Werson
- Department of Clinical Psychology, University of East Anglia, Norwich, UK
| | | | - Frances Reynolds
- College of Health and Life Sciences, Brunel University London, Uxbridge, UK
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Fawsitt CG, Thom HHZ, Hunt LP, Nemes S, Blom AW, Welton NJ, Hollingworth W, López-López JA, Beswick AD, Burston A, Rolfson O, Garellick G, Marques EMR. Choice of Prosthetic Implant Combinations in Total Hip Replacement: Cost-Effectiveness Analysis Using UK and Swedish Hip Joint Registries Data. Value Health 2019; 22:303-312. [PMID: 30832968 DOI: 10.1016/j.jval.2018.08.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 07/09/2018] [Accepted: 08/16/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Prosthetic implants used in total hip replacements (THR) have a range of bearing surface combinations (metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic, and metal-on-metal), head sizes (small [<36 mm in diameter] and large [≥36 mm in diameter]), and fixation techniques (cemented, uncemented, hybrid, and reverse hybrid). These can influence prosthesis survival, patients' quality of life, and healthcare costs. OBJECTIVES To compare the lifetime cost-effectiveness of implants for patients of different age and sex profiles. METHODS We developed a Markov model to compare the cost-effectiveness of various implants against small-head cemented metal-on-polyethylene implants. The probability that patients required 1 or more revision surgeries was estimated from analyses of more than 1 million patients in the UK and Swedish hip joint registries, for men and women younger than 55, 55 to 64, 65 to 74, 75 to 84, and 85 years and older. Implant and healthcare costs were estimated from local procurement prices, national tariffs, and the literature. Quality-adjusted life-years were calculated using published utility estimates for patients undergoing THR in the United Kingdom. RESULTS Small-head cemented metal-on-polyethylene implants were the most cost-effective for men and women older than 65 years. These findings were robust to sensitivity analyses. Small-head cemented ceramic-on-polyethylene implants were most cost-effective in men and women younger than 65 years, but these results were more uncertain. CONCLUSIONS The older the patient group, the more likely that the cheapest implants, small-head cemented metal-on-polyethylene implants, were cost-effective. We found no evidence that uncemented, hybrid, or reverse hybrid implants were the most cost-effective option for any patient group. Our findings can influence clinical practice and procurement decisions for healthcare payers worldwide.
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Affiliation(s)
- Christopher G Fawsitt
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Howard H Z Thom
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; NIHR Bristol Biomedical Research Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Linda P Hunt
- Musculoskeletal Research Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Szilard Nemes
- Swedish Hip Arthroplasty Register and Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ashley W Blom
- NIHR Bristol Biomedical Research Centre, Bristol Medical School, University of Bristol, Bristol, UK; Musculoskeletal Research Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicky J Welton
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; NIHR Bristol Biomedical Research Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - William Hollingworth
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - José A López-López
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ola Rolfson
- Swedish Hip Arthroplasty Register and Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Goran Garellick
- Swedish Hip Arthroplasty Register and Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elsa M R Marques
- Musculoskeletal Research Unit, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
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14
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Galaal K, Lopes A, Pritchard C, Barton A, Wingham J, Marques EMR, Faulds J, Palmer J, Vickery PJ, Ralph C, Ferreira N, Ewings P. Trial of intraoperative cell salvage versus transfusion in ovarian cancer (TIC TOC): protocol for a randomised controlled feasibility study. BMJ Open 2018; 8:e024108. [PMID: 30389760 PMCID: PMC6224724 DOI: 10.1136/bmjopen-2018-024108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/21/2018] [Accepted: 09/26/2018] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Ovarian cancer is the leading cause of death from gynaecological cancer, with more than 7000 new cases registered in the UK in 2014. In patients suitable for surgery, the National Institute of Health and Care Excellence guidance for treatment recommends surgical resection of all macroscopic tumour, followed by chemotherapy. The surgical procedure can be extensive and associated with substantial blood loss which is conventionally replaced with a donor blood transfusion. While often necessary and lifesaving, the use of donor blood is associated with increased risks of complications and adverse surgical outcomes. Intraoperative cell salvage (ICS) is a blood conservation strategy in which red cells collected from blood lost during surgery are returned to the patient thus minimising the use of donor blood. This is the protocol for a feasibility randomised controlled trial with an embedded qualitative study and feasibility economic evaluation. If feasible, a later definitive trial will test the effectiveness and cost-effectiveness of ICS reinfusion versus donor blood transfusion in ovarian cancer surgery. METHODS AND ANALYSIS Sixty adult women scheduled for primary or interval ovarian cancer surgery at participating UK National Health Service Trusts will be recruited and individually randomised in a 1:1 ratio to receive ICS reinfusion or donor blood (as required) during surgery. Participants will be followed up by telephone at 30 days postoperatively for adverse events monitoring and by postal questionnaire at 6 weeks and 3 monthly thereafter, to capture quality of life and resource use data. Qualitative interviews will capture participants' and clinicians' experiences of the study. ETHICS AND DISSEMINATION This study has been granted ethical approval by the South West-Exeter Research Ethics Committee (ref: 16/SW/0256). Results will be disseminated via peer-reviewed publications and will inform the design of a larger trial. TRIAL REGISTRATION NUMBER ISRCTN19517317.
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Affiliation(s)
- Khadra Galaal
- Gynaeoncology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | | | - Colin Pritchard
- Research, Development and Innovation, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Andrew Barton
- NIHR research and Design Services (South West), NIHR South West Research Design Service, Plymouth, UK
| | | | | | - John Faulds
- Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Joanne Palmer
- Research, Development and Innovation, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | | | - Catherine Ralph
- Department of Anaesthesia, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | | | - Paul Ewings
- NIHR research and Design Services (South West), NIHR South West Research Design Service, Plymouth, UK
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15
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Ijaz S, Thorley H, Porter K, Fleming C, Jones T, Kesten J, Mamluk L, Richards A, Marques EMR, Savović J. Interventions for preventing or treating malnutrition in homeless problem-drinkers: a systematic review. Int J Equity Health 2018; 17:8. [PMID: 29338739 PMCID: PMC5771104 DOI: 10.1186/s12939-018-0722-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/08/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Excessive drinking leads to poor absorption of nutrients and homeless problem-drinkers often have nutritionally inadequate diets. Depletion of nutrients such as vitamin B1 can lead to cognitive impairment, which can hinder efforts to reduce drinking or engage with services. This review aimed to assess effectiveness of interventions designed to prevent or treat malnutrition in homeless problem-drinkers. METHODS We systematically searched nine electronic databases and 13 grey literature sources for studies evaluating interventions to improve nutrition in homeless populations, without regional or language restrictions. Screening for inclusion was done in duplicate. One reviewer extracted data and assessed risk of bias, and another checked the extractions. Primary outcomes were nutrition status/deficiency, liver damage, and cognitive function. Secondary outcomes included abstinence, comorbidities, resource use, acceptability and engagement with intervention. Results were synthesised narratively. RESULTS We included 25 studies (2 Randomised Controlled Trials; 15 uncontrolled before and after; 7 surveys; 1 case-control). Nine studies evaluated educational and support interventions, five food provision, and three supplement provision. Eight studies evaluated a combination of these interventions. No two interventions were the same, and all studies were at high risk of bias. Nutritional status (intake/ deficiency) were reported in 11 studies and liver function in one. Fruit and vegetable intake improved with some education and support interventions (n = 4 studies) but not others (n = 2). Vitamin supplements appeared to improve vitamin deficiency levels in the blood (n = 2). Free or subsidised meals (n = 4) and food packs (n = 1) did not always fulfil dietary needs, but were usually considered acceptable by users. Some multicomponent interventions improved nutrition (n = 3) but acceptability varied (n = 3). No study reported cost effectiveness. CONCLUSIONS The evidence for any one intervention for improving malnutrition in homeless problem-drinkers was based on single studies at high risk of bias. Various food and supplement provision interventions appear effective in changing nutritional status in single studies. Educational and multicomponent interventions show improved nutritional behaviour in some studies but not others. Further better quality evidence is required before these interventions can be recommended for implementation. Any future studies should seek the end user input in their design and conduct. TRIAL REGISTRATION Registered with PROSPERO: CRD42015024247 .
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Affiliation(s)
- Sharea Ijaz
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT UK
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Helen Thorley
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT UK
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Clare Fleming
- Compass Health, The Compass Centre, 1 Jamaica Street, Bristol, BS2 8JP UK
| | - Tim Jones
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT UK
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Joanna Kesten
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT UK
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
- The National Institute for Health Research Health Protection Research Unit in Evaluation of Interventions, London, UK
| | - Loubaba Mamluk
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT UK
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Alison Richards
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT UK
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Elsa M. R. Marques
- Bristol Medical School, Musculoskeletal Research Unit, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Jelena Savović
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT UK
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
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López-López JA, Humphriss RL, Beswick AD, Thom HHZ, Hunt LP, Burston A, Fawsitt CG, Hollingworth W, Higgins JPT, Welton NJ, Blom AW, Marques EMR. Choice of implant combinations in total hip replacement: systematic review and network meta-analysis. BMJ 2017; 359:j4651. [PMID: 29097396 PMCID: PMC5683044 DOI: 10.1136/bmj.j4651] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2017] [Indexed: 01/29/2023]
Abstract
Objective To compare the survival of different implant combinations for primary total hip replacement (THR). Design Systematic review and network meta-analysis. Data sources Medline, Embase, The Cochrane Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and the EU Clinical Trials Register.Review methods Published randomised controlled trials comparing different implant combinations. Implant combinations were defined by bearing surface materials (metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic, or metal-on-metal), head size (large ≥36 mm or small <36 mm), and fixation technique (cemented, uncemented, hybrid, or reverse hybrid). Our reference implant combination was metal-on-polyethylene (not highly cross linked), small head, and cemented. The primary outcome was revision surgery at 0-2 years and 2-10 years after primary THR. The secondary outcome was the Harris hip score reported by clinicians.Results 77 studies were included in the systematic review, and 15 studies (3177 hips) in the network meta-analysis for revision. There was no evidence that the risk of revision surgery was reduced by other implant combinations compared with the reference implant combination. Although estimates are imprecise, metal-on-metal, small head, cemented implants (hazard ratio 4.4, 95% credible interval 1.6 to 16.6) and resurfacing (12.1, 2.1 to 120.3) increase the risk of revision at 0-2 years after primary THR compared with the reference implant combination. Similar results were observed for the 2-10 years period. 31 studies (2888 patients) were included in the analysis of Harris hip score. No implant combination had a better score than the reference implant combination.Conclusions Newer implant combinations were not found to be better than the reference implant combination (metal-on-polyethylene (not highly cross linked), small head, cemented) in terms of risk of revision surgery or Harris hip score. Metal-on-metal, small head, cemented implants and resurfacing increased the risk of revision surgery compared with the reference implant combination. The results were consistent with observational evidence and were replicated in sensitivity analysis but were limited by poor reporting across studies.Systematic review registration PROSPERO CRD42015019435.
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Affiliation(s)
- José A López-López
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachel L Humphriss
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew D Beswick
- Musculoskeletal Research Unit, University of Bristol, Southmead Hospital, Learning and Research Building (Level 1), Bristol BS10 5NB, UK
| | - Howard H Z Thom
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Linda P Hunt
- Musculoskeletal Research Unit, University of Bristol, Southmead Hospital, Learning and Research Building (Level 1), Bristol BS10 5NB, UK
| | - Amanda Burston
- Musculoskeletal Research Unit, University of Bristol, Southmead Hospital, Learning and Research Building (Level 1), Bristol BS10 5NB, UK
| | - Christopher G Fawsitt
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - William Hollingworth
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Julian P T Higgins
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicky J Welton
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ashley W Blom
- Musculoskeletal Research Unit, University of Bristol, Southmead Hospital, Learning and Research Building (Level 1), Bristol BS10 5NB, UK
| | - Elsa M R Marques
- Musculoskeletal Research Unit, University of Bristol, Southmead Hospital, Learning and Research Building (Level 1), Bristol BS10 5NB, UK
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Opmeer BC, Hollingworth W, Marques EMR, Margelyte R, Gunnell D. Extending the liaison psychiatry service in a large hospital in the UK: a before and after evaluation of the economic impact and patient care following ED attendances for self-harm. BMJ Open 2017; 7:e016906. [PMID: 28827260 PMCID: PMC5724115 DOI: 10.1136/bmjopen-2017-016906] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/05/2017] [Accepted: 07/04/2017] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To evaluate the impact of an expansion of liaison psychiatry services (LPS) on patient management, outcomes and treatment costs for emergency department (ED) attendances for self-harm. DESIGN Retrospective before and after cohort study using routinely collected Self-Harm Surveillance Register data. SETTING A large hospital in South West England. SUBJECTS Patients attending the ED for self-harm. INTERVENTIONS Extension of the LPS' working hours from 9:00 to 17:00, Monday to Friday to 8:00 to 22:00, 7 days a week, following a £250 000 annual investment MAIN OUTCOME MEASURES: Number and characteristics of ED attendances for self-harm. The before and after cohorts were compared in terms of key process measures, including proportion of patients receiving a psychosocial assessment, average length of hospital stay, waiting times for assessment, proportion of patients who self-discharged without an assessment, levels of repeat self-harm attendances and mean cost per patient attendance. RESULTS 298 patients attended ED for self-harm on 373 occasions between January and March 2014, and 318 patients attended on 381 occasions between January and March 2015. The proportion of ED attendances where patients received a psychosocial assessment increased from 57% to 68% (p=0.003), median waiting time decreased by 3 hours and 14 min (p=0.017), and the proportion of episodes where patients self-discharged without a psychosocial assessment decreased from 20% to 13% (p=0.022). The mean cost per patient attendance was marginally lower after the intervention (-£84; 95% CI -£254 to £77). CONCLUSIONS The extended LPS seems to have had a favourable effect on the management and outcomes of self-harm patients. The cost of extending the LPS' working hours might be partially offset by more efficient assessment and discharge. The impact of the extended LPS on the care of hospitalised patients with mental health problems other than self-harm requires further evaluation.
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Affiliation(s)
- Brent C Opmeer
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West at University Hospitals Bristol, Bristol, UK
- Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - William Hollingworth
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West at University Hospitals Bristol, Bristol, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Ruta Margelyte
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West at University Hospitals Bristol, Bristol, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - David Gunnell
- The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West at University Hospitals Bristol, Bristol, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Beattie A, Marques EMR, Barber M, Greenwood R, Ingram J, Ayres R, Neale J, Rees A, Coleman B, Hickman M. Script in a Day intervention for individuals who are injecting opioids: a feasibility randomized control trial. J Public Health (Oxf) 2016; 38:712-721. [PMID: 28158697 DOI: 10.1093/pubmed/fdv161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Angela Beattie
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Elsa M R Marques
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Rosemary Greenwood
- NIHR Research Design Service-South West, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Jennifer Ingram
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Williamson H, Hamlet C, White P, Marques EMR, Cadogan J, Perera R, Rumsey N, Hayward L, Harcourt D. Study protocol of the YP Face IT feasibility study: comparing an online psychosocial intervention versus treatment as usual for adolescents distressed by appearance-altering conditions/injuries. BMJ Open 2016; 6:e012423. [PMID: 27697878 PMCID: PMC5073580 DOI: 10.1136/bmjopen-2016-012423] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION A significant number of adolescents suffer extensive and enduring difficulties such as social anxiety, body image dissatisfaction, low self-esteem and bullying as a result of conditions or injuries that affect their appearance (eg, craniofacial and skin conditions, treatment side effects and scarring). Evidence-based psychosocial interventions to meet their specific needs are currently lacking. YP Face IT, developed by the UK's Centre for Appearance Research in collaboration with clinical experts and young people, is an innovative online psychosocial intervention designed to offer this group immediate support, advice and coping strategies. It has been endorsed by young people, their parents/carers, GPs, clinical psychologists and health professionals working with those affected by appearance-related conditions. METHODS AND ANALYSIS Young people aged 12-17 with an appearance-altering condition/injury that self-identify as experiencing appearance-related distress, teasing or bullying will be invited to participate via GP practices and UK charities. Consenting participants will be randomised to the intervention (YP Face IT) or the treatment as usual (TAU) control group. Outcome measures will be completed by young people and their parents/carers at baseline, 13, 26 and 52 weeks. Primary outcome measures will be the Body Esteem Scale and the Social Anxiety Scale for Adolescents. Participants will complete other health-related outcome measures and resource use questionnaires for health economic analysis. We will assess recruitment rates, acceptability of the YP Face IT programme, adherence and retention to treatment, questionnaire completion rates, variation of TAU in Primary Care and the feasibility of GP practice staff supervising young people's use of YP Face IT. ETHICS AND DISSEMINATION This feasibility trial protocol (V.1, 3 March 2014), received a favourable ethical opinion from the NRES Committee South West-Frenchay (reference number 14/SW/0058). Findings will be disseminated through academic peer-reviewed publications, conferences and to participating GP practices and charities supporting those with conditions affecting appearance. TRIAL REGISTRATION NUMBER ISRCTN40650639; Pre-results.
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Affiliation(s)
- Heidi Williamson
- Faculty of Health and Applied Sciences, Centre for Appearance Research, University of the West of England Bristol, Bristol, UK
| | - Claire Hamlet
- Centre for Appearance Research, University of the West of England, Bristol, UK
| | - Paul White
- University of the West of England Bristol, Bristol, UK
| | - Elsa M R Marques
- School of Social and Community Medicine, University of Bristol and the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research, Bristol, UK
| | - Julia Cadogan
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Rohan Perera
- Pembroke Road Surgery, Bristol Clinical Commissioning Group, Bristol, UK
| | - Nichola Rumsey
- Centre for Appearance Research, University of the West of England, Bristol, UK
| | | | - Diana Harcourt
- Faculty of Health and Applied Sciences, Centre for Appearance Research, University of the West of England Bristol, Bristol, UK
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Marques EMR, Humphriss R, Welton NJ, Higgins JPT, Hollingworth W, Lopez-Lopez JA, Thom H, Hunt LP, Blom AW, Beswick AD. The choice between hip prosthetic bearing surfaces in total hip replacement: a protocol for a systematic review and network meta-analysis. Syst Rev 2016; 5:19. [PMID: 26831503 PMCID: PMC4736145 DOI: 10.1186/s13643-016-0189-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 01/13/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Prosthetic hip implants have many combinations of bearing surface materials, sizes, and fixation techniques, which can determine the quality of life of patients after primary total hip replacement (THR) and the likelihood of needing revision surgery. When an implant fails, patients require revision THR, which is distressing to the patient and expensive for the health care payer. Primary THR is one of the most common elective procedures performed worldwide, with over 300,000 performed annually in the USA and over 80,000 in England and Wales. It is important to review all available randomised controlled trial (RCT) evidence to determine which implant bearing surface materials, size, and fixation technique are most effective for patients. METHODS/DESIGN This is a protocol for a systematic review and meta-analysis of RCTs comparing outcomes of hip implant bearing surfaces, size, and fixation techniques used in THR. Implant combinations compared in the literature include four bearing surface combinations (metal-on-polyethylene, metal-on-metal, ceramic-on-polyethylene, and ceramic-on-ceramic); two femoral head sizes (large vs small heads); and four fixation techniques (uncemented, cemented, hybrid, and reverse hybrids). The primary outcome will be revision surgery. We will also collect data on patient characteristics, mortality, quality of life, and other outcomes. In network meta-analysis, we will estimate the relative effectiveness of every implant bearing surface, head size (large vs small), and fixation permutation, using evidence where implants have been compared directly in an RCT and indirectly through common comparators in different RCTs. DISCUSSION There has been much debate about materials used for prosthetic implants in THR. Different combinations of prosthetic materials, sizes, and fixation, can vary widely in cost and fail at different rates for different patient groups. Given the number of THRs performed yearly, and the increasing use of expensive implants, it is important to review evidence to inform surgeons, patients, and health care providers of optimal implant bearing combinations for given patient characteristics. This review will inform a cost-effectiveness model that will include evidence from other sources, to determine the most effective and cost-effective implant bearing combination for patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015019435.
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Affiliation(s)
- Elsa M R Marques
- School of Social and Community Medicine, University of Bristol Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Rachel Humphriss
- School of Social and Community Medicine, University of Bristol Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Nicky J Welton
- School of Social and Community Medicine, University of Bristol Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Julian P T Higgins
- School of Social and Community Medicine, University of Bristol Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - William Hollingworth
- School of Social and Community Medicine, University of Bristol Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Jose A Lopez-Lopez
- School of Social and Community Medicine, University of Bristol Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Howard Thom
- School of Social and Community Medicine, University of Bristol Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Linda P Hunt
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK.
| | - Ashley W Blom
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK.
| | - Andrew D Beswick
- Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK.
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Ellis-Hill C, Gracey F, Thomas S, Lamont-Robinson C, Thomas PW, Marques EMR, Grant M, Nunn S, Cant RPI, Galvin KT, Reynolds F, Jenkinson DF. 'HeART of Stroke (HoS)', a community-based Arts for Health group intervention to support self-confidence and psychological well-being following a stroke: protocol for a randomised controlled feasibility study. BMJ Open 2015; 5:e008888. [PMID: 26243555 PMCID: PMC4538255 DOI: 10.1136/bmjopen-2015-008888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 06/23/2015] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Over 152,000 people in the UK have strokes annually and a third experience residual disability. Low mood also affects a third of stroke survivors; yet psychological support is poor. While Arts for Health interventions have been shown to improve well-being in people with mild-to-moderate depression post-stroke, their role in helping people regain sense of self, well-being and confidence has yet to be evaluated. The main aim of this study is to explore the feasibility of conducting a pragmatic multicentre randomised controlled trial to assess the effectiveness and cost-effectiveness of an Arts for Health group intervention ('HeART of Stroke' (HoS)) for stroke survivors. HoS is a 10-session artist-facilitated group intervention held in the community over 14 weeks. It offers a non-judgemental, supportive environment for people to explore sense of self, potentially enhancing well-being and confidence. METHODS AND ANALYSIS Sixty-four people, up to 2 years post-stroke, recruited via secondary care research staff or community stroke/rehabilitation teams in two UK centres will be randomised to either HoS plus usual care or usual care only. Self-reported outcomes, measured at baseline and approximately 5 months postrandomisation, will include stroke-related, well-being, mood, self-esteem, quality of life and process measures. Analyses will focus on estimating key feasibility parameters (eg, rates of recruitment, retention, intervention attendance). We will develop outcome and resource use data collection methods to inform an effectiveness and cost-effectiveness analysis in the future trial. Interviews, with a sample of participants, will explore the acceptability of the intervention and study processes, as well as experiences of the HoS group. ETHICS AND DISSEMINATION National Health Service (NHS), Research and Development and University ethical approvals have been obtained. Two peer-reviewed journal publications are planned plus one service user led publication. Findings will be disseminated at key national conferences, local stakeholder events and via institutional websites. TRIAL REGISTRATION NUMBER ISRCTN99728983.
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Affiliation(s)
- Caroline Ellis-Hill
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
| | - Fergus Gracey
- Department of Clinical Psychology, University of East Anglia, Norwich, UK
- Oliver Zangwill Centre, Cambridgeshire Community Services NHS Trust, Ely, Cambridgeshire, UK
| | - Sarah Thomas
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
| | | | - Peter W Thomas
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, Dorset, UK
| | - Elsa M R Marques
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Mary Grant
- Stroke Research, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Dorset, UK
| | - Samantha Nunn
- Oliver Zangwill Centre, Cambridgeshire Community Services NHS Trust, Ely, Cambridgeshire, UK
| | - Robin P I Cant
- Service User (formerly of Canterbury Christ Church University), Kent, UK
| | - Kathleen T Galvin
- Faculty of Health and Social Care, University of Hull, Hull, Yorkshire, UK
| | - Frances Reynolds
- College of Health and Life Sciences, Brunel University London, UK
| | - Damian F Jenkinson
- Stroke Unit, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Dorset, UK
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Marques EMR, Jones HE, Elvers KT, Pyke M, Blom AW, Beswick AD. Local anaesthetic infiltration for peri-operative pain control in total hip and knee replacement: systematic review and meta-analyses of short- and long-term effectiveness. BMC Musculoskelet Disord 2014; 15:220. [PMID: 24996539 PMCID: PMC4118275 DOI: 10.1186/1471-2474-15-220] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 06/30/2014] [Indexed: 12/17/2022] Open
Abstract
Background Surgical pain is managed with multi-modal anaesthesia in total hip replacement (THR) and total knee replacement (TKR). It is unclear whether including local anaesthetic infiltration before wound closure provides additional pain control. Methods We performed a systematic review of randomised controlled trials of local anaesthetic infiltration in patients receiving THR or TKR. We searched MEDLINE, Embase and Cochrane CENTRAL to December 2012. Two reviewers screened abstracts, extracted data, and contacted authors for unpublished outcomes and data. Outcomes collected were post-operative pain at rest and during activity after 24 and 48 hours, opioid requirement, mobilisation, hospital stay and complications. When feasible, we estimated pooled treatment effects using random effects meta-analyses. Results In 13 studies including 909 patients undergoing THR, patients receiving local anaesthetic infiltration experienced a greater reduction in pain at 24 hours at rest by standardised mean difference (SMD) -0.61 (95% CI -1.05, -0.16; p = 0.008) and by SMD -0.43 (95% CI -0.78 -0.09; p = 0.014) at 48 hours during activity. In TKR, diverse multi-modal regimens were reported. In 23 studies including 1439 patients undergoing TKR, local anaesthetic infiltration reduced pain on average by SMD -0.40 (95% CI -0.58, -0.22; p < 0.001) at 24 hours at rest and by SMD -0.27 (95% CI -0.50, -0.05; p = 0.018) at 48 hours during activity, compared with patients receiving no infiltration or placebo. There was evidence of a larger reduction in studies delivering additional local anaesthetic after wound closure. There was no evidence of pain control additional to that provided by femoral nerve block. Patients receiving local anaesthetic infiltration spent on average an estimated 0.83 (95% CI 1.54, 0.12; p = 0.022) and 0.87 (95% CI 1.62, 0.11; p = 0.025) fewer days in hospital after THR and TKR respectively, had reduced opioid consumption, earlier mobilisation, and lower incidence of vomiting. Few studies reported long-term outcomes. Conclusions Local anaesthetic infiltration is effective in reducing short-term pain and hospital stay in patients receiving THR and TKR. Studies should assess whether local anaesthetic infiltration can prevent long-term pain. Enhanced pain control with additional analgesia through a catheter should be weighed against a possible infection risk.
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Affiliation(s)
- Elsa M R Marques
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK.
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