A novel approach to evaluating the UK childhood immunisation schedule: estimating the effective coverage vector across the entire vaccine programme

BACKGROUND: The availability of new vaccines can prompt policy makers to consider changes to the routine childhood immunisation programme in the UK. Alterations to one aspect of the schedule may have implications for other areas of the programme (e.g. adding more injections could reduce uptake of vaccines featuring later in the schedule). Colleagues at the Department of Health (DH) in the UK therefore wanted to know whether assessing the impact across the entire programme of a proposed change to the UK schedule could lead to different decisions than those made on the current case-by-case basis. This work is a first step towards addressing this question. METHODS: A novel framework for estimating the effective coverage against all of the diseases within a vaccination programme was developed. The framework was applied to the current (August 2015) UK childhood immunisation programme, plausible extensions to it in the foreseeable future (introducing vaccination against Meningitis B and/or Hepatitis B) and a "what-if" scenario regarding a Hepatitis B vaccine scare that was developed in close collaboration with DH. RESULTS: Our applications of the framework demonstrate that a programme-view of hypothetical changes to the schedule is important. For example, we show how introducing Hepatitis B vaccination could negatively impact aspects of the current programme by reducing uptake of vaccines featuring later in the schedule, and illustrate that the potential benefits of introducing any new vaccine are susceptible to behaviour changes affecting uptake (e.g. a vaccine scare). We show how it may be useful to consider the potential benefits and scheduling needs of all vaccinations on the horizon of interest rather than those of an individual vaccine in isolation, e.g. how introducing Meningitis B vaccination could saturate the early (2-month) visit, thereby potentially restricting scheduling options for Hepatitis B immunisation should it be introduced to the programme in the future. CONCLUSIONS: Our results demonstrate the potential benefit of considering the programme-wide impact of changes to an immunisation schedule, and our framework is an important step in the development of a means for systematically doing so

The CEA Second-Look Trial: a randomised controlled trial of carcinoembryonic antigen prompted reoperation for recurrent colorectal cancer

Objective In patients who have undergone a potentially curative resection of colorectal cancer, does a ‘second-look’ operation to resect recurrence, prompted by monthly monitoring of carcinoembryonic antigen, confer a survival benefit?Design A randomised controlled trial recruiting patients from 1982 to 1993 was recovered under the Restoring Invisible and Abandoned Trials (RIAT) initiative.Setting 58 hospitals in the UK.Participants From 1982 to 1993, 1447 patients were enrolled. Of these 216 met the criteria for carcinoembryonic antigen (CEA) elevation and were randomised to ‘Aggressive’ or ‘Conventional’ arms.Interventions ‘Second-look’ surgery with intention to remove any recurrence discovered.Primary outcome measure Survival.Results By February 1993, 91/108 patients had died in the ‘Aggressive arm’ and 88/108 in the ‘Conventional’ arm (relative risk=1.16, 95% CI 0.87 to 1.37). By 2011 a further 25 randomised patients had died. Kaplan-Meier analysis showed no difference in long-term survival.Conclusions The trial was closed in 1993 following a recommendation from the Data Monitoring Committee that it was highly unlikely that any survival advantage would be demonstrated for CEA prompted second-look surgery. This conclusion was confirmed by repeat analysis of survival times after 20 years.Trial registration number ISRCTN76694943

On the modelling and performance measurement of service networks with heterogeneous customers

Service networks are common throughout the modern world, yet understanding how their individual services effect each other and contribute to overall system performance can be difficult. An important metric in these systems is the quality of service. This is an often overlooked measure when modelling and relates to how customers are affected by a service. Presented is a novel perspective for evaluating the performance of multi-class queueing networks through a combination of operational performance and service quality—denoted the “flow of outcomes”. Here, quality is quantified by customers moving between or remaining in classes as a result of receiving service or lacking service. Importantly, each class may have different flow parameters, hence the positive/negative impact of service quality on the system’s operational performance is captured. A fluid–diffusion approximation for networks of stochastic queues is used since it allows for several complex flow dynamics: the sequential use of multiple services; abandonment and possible rejoin; reuse of the same service; multiple customers classes; and, class and time dependent parameters. The scalability of the approach is a significant benefit since, the modelled systems may be relatively large, and the included flow dynamics may render the system analytically intractable or computationally burdensome. Under the right conditions, this method provides a framework for quickly modelling large time-dependent systems. This combination of computational speed and the “flow of outcomes” provides new avenues for the analysis of multi-class service networks where both service quality and operational efficiency interact

Operational Research Approaches

Operational research is a collection of modelling techniques used to structure, analyse, and solve problems related to the design and operation of complex human systems. While many argue that operational research should play a key role in improving healthcare services, staff may be largely unaware of its potential applications. This Element explores operational research's wartime origins and introduce several approaches that operational researchers use to help healthcare organisations: address well-defined decision problems; account for multiple stakeholder perspectives; and describe how system performance may be impacted by changing the configuration or operation of services. The authors draw on examples that illustrate the valuable perspective that operational research brings to improvement initiatives and the challenges of implementing and scaling operational research solutions. They discuss how operational researchers are working to surmount these problems and suggest further research to help operational researchers have greater beneficial impact in healthcare improvement. This title is also available as Open Access on Cambridge Core

Athletes’ Expectations About Sport-Injury Rehabilitation: A Cross-Cultural Study

Context: Athletes enter injury rehabilitation with certain expectations about the recovery process, outcomes, and the professional providing treatment. Their expectations influence the effectiveness of the assistance received and affect the overall rehabilitation process. Expectations may vary depending on numerous factors such as sport experience, gender, sport-type and cultural background. Unfortunately, limited information is available on athletes’ expectations about sport injury rehabilitation. Objective: To examine possible differences in athletes’ expectations about sport injury rehabilitation based on their country of residence and type of sport (physical contact versus non-physical contact). Design: A cross-sectional design. Setting: Recreational, collegiate, and professional athletes from the United States (US), United Kingdom (UK) and Finland were surveyed. Participants: Of the 1209 athletes ranging from 12 to 80 years of age (Mage = 23.46 ± 7.91), of which 529 US [80%], 253 UK [86%], and 199 Finnish [82%] provided details of their geographical location, were included in the final analyses. Main Outcome Measures: The Expectations about Athletic Training (EAAT) questionnaire was used to determine athletes’ expectations about personal commitment, facilitative conditions, and the expertise of the sports medicine professional (Clement et al., 2012). Results: 3x2 MANCOVA revealed significant main effects for country (p = .0001, ηp2 = .055) and sport type (p = .0001, ηp2 = .023). Specifically, US athletes were found to have higher expectations of personal commitment and facilitative conditions than their UK and Finnish counterparts. Athletes participating in physical contact sports had higher expectations of facilitative conditions and the expertise of the sports medicine professional (SMP) as compared to athletes participating in non-physical contact sports. Conclusions: SMPs, especially those in the US, should consider the sport and environment when providing services. In addition, SMPs need to highlight and demonstrate their expertise durin

A Mathematical Modelling Approach for Systems Where the Servers Are Almost Always Busy

The design and implementation of new configurations of mental health services to meet local needs is a challenging problem. In the UK, services for common mental health disorders such as anxiety and depression are an example of a system running near or at capacity, in that it is extremely rare for the queue size for any given mode of treatment to fall to zero. In this paper we describe a mathematical model that can be applied in such circumstances. The model provides a simple way of estimating the mean and variance of the number of patients that would be treated within a given period of time given a particular configuration of services as defined by the number of appointments allocated to different modes of treatment and the referral patterns to and between different modes of treatment. The model has been used by service planners to explore the impact of different options on throughput, clinical outcomes, queue sizes, and waiting times. We also discuss the potential for using the model in conjunction with optimisation techniques to inform service design and its applicability to other contexts

A First Study of the Structure of the Virtual Photon at HERA

The production of two or more jets of hadrons in photoproduction events at the HERA e+p collider has been studied using the ZEUS detector. By tagging the final state positron, two samples of event have been isolated where the photon exchanged between proton and positron is quasi-real (of virtuality p2< 0.02 GeV2) and virtual (0.1 < p2< 0.55 GeV2) respectively. It is shown that photons in both P2 ranges show resolved structure. The P2 evolution of the structure of the photon is studied by measuring the relative contribution of direct and resolved photon processes to the cross-section for the production of two or more jets. Events have been classified as direct or resolved based upon the value of the final state observable xgammaobs The data suggest that the contribution from resolved photon processes is suppressed relative to that from direct photon processes as P2 rises and are in general agreement with leading order calculations. Limited statistics in the data prevent a more quantitative study

Using visualisation methods to analyse referral networks within community health care among patients aged 65 years and over

Community health care services are considered integral to overcoming future problems in health care. However, this sector faces its own challenges, such as how to organise services to provide coordinated care given: their physical distribution, patients using multiple services, increased patient use and differing patient needs. The aim of this work was to explore, analyse and understand patterns in community referrals for patients aged 65 years and over, and their use of multiple services through data visualisation. Working with a large community provider, these methods helped researchers and service managers to investigate questions that were otherwise difficult to answer from raw data. Each map focuses on a different characteristic of community referrals: patients reusing services, concurrent uses of different services and patterns of subsequent referrals. We apply these methods to routine patient data and discuss their implications in designing of a single point of access - a service for streamlining referrals