Economic analysis of service and delivery interventions in health care

There are well-developed guidelines for economic evaluation of clearly defined clinical interventions, but no such guidelines for economic analysis of service interventions. Distinctive challenges for analysis of service interventions include diffuse effects, wider system impacts, and variability in implementation, costs and effects. Cost-effectiveness evidence is as important for service interventions as for clinical interventions. There is also an important role for wider forms of economic analysis to increase our general understanding of context, processes and behaviours in the care system. Methods exist to estimate the cost-effectiveness of service interventions before and after introduction, to measure patient and professional preferences, to reflect the value of resources used by service interventions, and to capture wider system effects, but these are not widely applied. Future priorities for economic analysis should be to produce cost-effectiveness evidence and to increase our understanding of how service interventions affect, and are affected by, the care system

The Role of Psychological Readiness in Recovery from ACL Injury in Female Athletes

The Anterior Cruciate Ligament (ACL) injury is common in sports, with female athletes facing a disproportionately higher risk in comparison to male athletes.1 This susceptibility is the result of a complex relationship between various factors including anatomical, biomechanical, hormonal, neuromuscular, and environmental influences.2 In addition, the unique challenges that females face with respect to sports, violence, body image, and family planning create additional stressors that may further contribute to an increased risk for injury.3,4 Following ACL Reconstruction (ACLR) surgery, these gender discrepancies carry over into recovery as female athletes exhibit decreased rates of return to sport (RTS) compared to male athletes.5,

Saintly ecstasies: the appropriation and secularisation of saintly imagery in the paintings and poems of Dante Gabriel Rossetti

Using unpublished source material at Princeton University, the University of British Columbia, the British Library and the National Art Library in the V&A, this thesis aims to broaden current scholarly understanding regarding Rossetti's exposure to, interest in, and subsequent appropriation of aspects of monastic life and saintly legend in his religious and secular paintings and poems. The intention of part one of this thesis is to discuss and analyse Rossetti's early interest in monasticism and the legends of the saints. Rossetti's attraction to Catholic ritual and ceremony, both in terms of its aesthetic impact and the feelings of awe it engendered, will form the background to a discussion of his admiration for pre-Reformation art. The concern which he displayed in his own paintings and poems for saintly legend and theological mysteries will be shown to have its origins in early Christian art, as well as in the apocryphal lives of the saints and the writings of the Church Fathers, which had seen a resurgence in popularity in the wake of the Oxford Movement. Rossetti's growing fascination with art as a vehicle for the conveyance of religious ideas will be considered in relation to the early and mid-nineteenth century revival of interest in the medieval painter-monk and in the practice of illumination. Rossetti's 1856 watercolour Fra Pace will be examined in this context. The pertinence of the example of St Luke, who used his art as a preaching tool, will also be considered, Rossetti having returned to this concept directly, and obliquely, throughout his career in both his visual and poetic art. The influence of the quasi-monastic Nazarene painters, also called the German Brotherhood of St Luke, will be examined. Rossetti's suggestion of "Brotherhood" as an appendage to "Pre-Raphaelite" will be considered within a specifically monastic context, looking at the artist's family history, analogous artistic communities, and the revival of interest in ascetic institutions within the nineteenth century. The extent to which the works of the Pre-Raphaelite group showed a basis towards asceticism will be analysed, as will contemporary reactions to this

Is telephone health coaching a useful population health strategy for supporting older people with multimorbidity? : An evaluation of reach, effectiveness and cost-effectiveness using a 'trial within a cohort'

BACKGROUND: Innovative ways of delivering care are needed to improve outcomes for older people with multimorbidity. Health coaching involves 'a regular series of phone calls between patient and health professional to provide support and encouragement to promote healthy behaviours'. This intervention is promising, but evidence is insufficient to support a wider role in multimorbidity care. We evaluated health coaching in older people with multimorbidity. METHODS: We used the innovative 'Trials within Cohorts' design. A cohort was recruited, and a trial was conducted using a 'patient-centred' consent model. A randomly selected group within the cohort were offered the intervention and were analysed as the intervention group whether they accepted the offer or not. The intervention sought to improve the skills of patients with multimorbidity to deal with a range of long-term conditions, through health coaching, social prescribing and low-intensity support for low mood. RESULTS: We recruited 4377 older people, and 1306 met the eligibility criteria (two or more long-term conditions and moderate 'patient activation'). We selected 504 for health coaching, and 41% consented. More than 80% of consenters received the defined 'dose' of 4+ sessions. In an intention-to-treat analysis, those selected for health coaching did not improve on any outcome (patient activation, quality of life, depression or self-care) compared to usual care. We examined health care utilisation using hospital administrative and self-report data. Patients selected for health coaching demonstrated lower levels of emergency care use, but an increase in the use of planned services and higher overall costs, as well as a quality-adjusted life year (QALY) gain. The incremental cost per QALY was £8049, with a 70-79% probability of being cost-effective at conventional levels of willingness to pay. CONCLUSIONS: Health coaching did not lead to significant benefits on the primary measures of patient-reported outcome. This is likely related to relatively low levels of uptake amongst those selected for the intervention. Demonstrating effectiveness in this design is challenging, as it estimates the effect of being selected for treatment, regardless of whether treatment is adopted. We argue that the treatment effect estimated is appropriate for health coaching, a proactive model relevant to many patients in the community, not just those seeking care. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ( ISRCTN12286422 )

Arrival by ambulance explains variation in mortality by time of admission : retrospective study of admissions to hospital following emergency department attendance in England

BACKGROUND: Studies finding higher mortality rates for patients admitted to hospital at weekends rely on routine administrative data to adjust for risk of death, but these data may not adequately capture severity of illness. We examined how rates of patient arrival at accident and emergency (A&E) departments by ambulance-a marker of illness severity-were associated with in-hospital mortality by day and time of attendance. METHODS: Retrospective observational study of 3 027 946 admissions to 140 non-specialist hospital trusts in England between April 2013 and February 2014. Patient admissions were linked with A&E records containing mode of arrival and date and time of attendance. We classified arrival times by day of the week and daytime (07:00 to 18:59) versus night (19:00 to 06:59 the following day). We examined the association with in-hospital mortality within 30 days using multivariate logistic regression. RESULTS: Over the week, 20.9% of daytime arrivals were in the highest risk quintile compared with 18.5% for night arrivals. Daytime arrivals on Sundays contained the highest proportion of patients in the highest risk quintile at 21.6%. Proportions of admitted patients brought in by ambulance were substantially higher at night and higher on Saturday (61.1%) and Sunday (60.1%) daytimes compared with other daytimes in the week (57.0%). Without adjusting for arrival by ambulance, risk-adjusted mortality for patients arriving at night was higher than for daytime attendances on Wednesday (0.16 percentage points). Compared with Wednesday daytime, risk-adjusted mortality was also higher on Thursday night (0.15 percentage points) and increased throughout the weekend from Saturday daytime (0.16 percentage points) to Sunday night (0.26 percentage points). After adjusting for arrival by ambulance, the raised mortality only reached statistical significance for patients arriving at A&E on Sunday daytime (0.17 percentage points). CONCLUSION: Using conventional risk-adjustment methods, there appears to be a higher risk of mortality following emergency admission to hospital at nights and at weekends. After accounting for mode of arrival at hospital, this pattern changes substantially, with no increased risk of mortality following admission at night or for any period of the weekend apart from Sunday daytime. This suggests that risk-adjustment based on inpatient administrative data does not adequately account for illness severity and that elevated mortality at weekends and at night reflects a higher proportion of more severely ill patients arriving by ambulance at these times

Mapping the disease-specific LupusQoL to the SF-6D

Purpose To derive a mapping algorithm to predict SF-6D utility scores from the non-preference-based LupusQoL and test the performance of the developed algorithm on a separate independent validation data set. Method LupusQoL and SF-6D data were collected from 320 patients with systemic lupus erythematosus (SLE) attending routine rheumatology outpatient appointments at seven centres in the UK. Ordinary least squares (OLS) regression was used to estimate models of increasing complexity in order to predict individuals’ SF-6D utility scores from their responses to the LupusQoL questionnaire. Model performance was judged on predictive ability through the size and pattern of prediction errors generated. The performance of the selected model was externally validated on an independent data set containing 113 female SLE patients who had again completed both the LupusQoL and SF-36 questionnaires. Results Four of the eight LupusQoL domains (physical health, pain, emotional health, and fatigue) were selected as dependent variables in the final model. Overall model fit was good, with R2 0.7219, MAE 0.0557, and RMSE 0.0706 when applied to the estimation data set, and R2 0.7431, MAE 0.0528, and RMSE 0.0663 when applied to the validation sample. Conclusion This study provides a method by which health state utility values can be estimated from patient responses to the non-preference-based LupusQoL, generalisable beyond the data set upon which it was estimated. Despite concerns over the use of OLS to develop mapping algorithms, we find this method to be suitable in this case due to the normality of the SF-6D data

Changes in admission thresholds in English Emergency Departments

YesBackground: The most common route to a hospital bed in an emergency is via an emergency department (ED). Many recent initiatives and interventions have the objective of reducing the number of unnecessary emergency admissions. We aimed to assess whether ED admission thresholds had changed over time taking account of the casemix of patients arriving at ED. Methods: We conducted a retrospective cross-sectional analysis of more than 20 million attendances at 47 consultant-led emergency departments in England between April 2010 and March 2015. We used mixed- effects logistic regression to estimate the odds of a patient being admitted to hospital and the impact of a range of potential explanatory variables. Models were developed and validated for four attendance subgroups : ambulance-conveyed children; walk-in children; ambulance-conveyed adults; and walk-in adults. Results: 23.8% of attendances were for children aged under 18 years, 49.7% were female and 30.0% were conveyed by ambulance. The number of ED attendances increased by 1.8% per annum between April 2010 – March 2011 (year 1) and April 2014 –March 2015 (year 5). The proportion of these attendances that were admitted to hospital changed little between year 1 (27.0%) and year 5 (27.5%). However, after adjusting for patient and attendance characteristics the odds of admission over the five year period had reduced by: 15.2% (95% CI 13.4% - 17.0%) for ambulance-conveyed children; 22.6% (95% CI 21.7%-23.5%) for walk-in children; 20.9% (95% CI 4%-21.5%) for ambulance conveyed adults; and 22.9% (95% CI 22.4%-23.5%) for walk-in adults. Conclusions: The casemix-adjusted odds of admission via ED to NHS hospitals in England have decreased since April 2010. EDs are admitting a similar proportion of patients to hospital despite increases in the complexity and acuity of presenting patients. Without these threshold changes, the number of emergency admissions would have been 11.9% higher than was the case in year 5

Environment-Organism Feedbacks Drive Changes in Ecological Interactions.

Ecological interactions are foundational to our understanding of community composition and function. While interactions are known to change depending on the environmental context, it has generally been assumed that external environmental factors are responsible for driving these dependencies. Here, we derive a theoretical framework which instead focuses on how intrinsic environmental changes caused by the organisms themselves alter interaction values. Our central concept is the 'instantaneous interaction', which captures the feedback between the current environmental state and organismal growth, generating spatiotemporal context-dependencies as organisms modify their environment over time and/or space. We use small microbial communities to illustrate how this framework can predict time-dependencies in a toxin degradation system, and relate time- and spatial-dependencies in crossfeeding communities. By re-centring the relationship between organisms and their environment, our framework predicts the variations in interactions wherever intrinsic, organism-driven environmental change dominates over external drivers